Basic Information
| Provider Information | |||||||||
| NPI: | 1760487284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROSS TIMBERS HEALTH CLINICS, INC. | ||||||||
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| OtherOrganizationName: | EASTLAND COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W REYNOSA AVE | ||||||||
| Address2: | |||||||||
| City: | DE LEON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764441630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548935895 | ||||||||
| FaxNumber: | 2548935222 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 W COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | EASTLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764482600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548935895 | ||||||||
| FaxNumber: | 2548935222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | HILL | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2548935895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 126862506 | 05 | TX | MEDICAID |