Basic Information
| Provider Information | |||||||||
| NPI: | 1649462482 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEWTON FAMILY CLINIC, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NEWTON FAMILY RURAL HEALTH CLINIC @ JASPER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 561 STATE ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759515134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093848990 | ||||||||
| FaxNumber: | 4093849921 | ||||||||
| Practice Location | |||||||||
| Address1: | 561 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759515134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093848990 | ||||||||
| FaxNumber: | 4093849921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THIBODAUX | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DATA OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4093848990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEWTON FAMILY CLINIC, PA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | G3189 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR1300X | G3189 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | PA02232 | 01 | TX | PA LICENCE | OTHER | 571660 | 01 | TX | NURSES LICENCES | OTHER | 742386 | 01 | TX | NURSES LICENSE | OTHER |