Basic Information
| Provider Information | |||||||||
| NPI: | 1730182585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT WORTH NORTHSIDE COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FWNCHC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 N MAIN ST | ||||||||
| Address2: | STE 215 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761068576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173780855 | ||||||||
| FaxNumber: | 8173780861 | ||||||||
| Practice Location | |||||||||
| Address1: | 2106 N. MAIN | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761068570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176254254 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HERRERA | ||||||||
| AuthorizedOfficialFirstName: | EDDY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8173780855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | Y | Agencies | Voluntary or Charitable |
No ID Information.