Basic Information
| Provider Information | |||||||||
| NPI: | 1699831685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH PLAINS COMMUNITY ACTION ASSOCIATION, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH PLAINS COMMUNITY ACTION ASSOCIATION, INC. CBA PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 610 | ||||||||
| Address2: | |||||||||
| City: | LEVELLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793360610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8068946104 | ||||||||
| FaxNumber: | 8068970835 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | LEVELLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793364044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8068947872 | ||||||||
| FaxNumber: | 8068941621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEENAN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8068947872 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000652300 | 05 | TX | MEDICAID |