Basic Information
| Provider Information | |||||||||
| NPI: | 1659593028 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FALLS COMMUNITY HOSPITAL AND CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FCHC RUCKER CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60 | ||||||||
| Address2: | |||||||||
| City: | MARLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766610060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
| FaxNumber: | 2548836066 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N PEARL ST | ||||||||
| Address2: | |||||||||
| City: | MART | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766641142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
| FaxNumber: | 2548836066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2548033561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FALLS COMMUNITY HOSPITAL AND CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | E0892 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 167931801 | 05 | TX | MEDICAID | 1679318-01 | 01 | TX | PTAN | OTHER | 167931802 | 05 | TX | MEDICAID |