Basic Information
| Provider Information | |||||||||
| NPI: | 1790777696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACK COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAITH COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 CHISHOLM TRL | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764581403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405676633 | ||||||||
| FaxNumber: | 9405672895 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 CHISHOLM TRL | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405676633 | ||||||||
| FaxNumber: | 9405672895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9405676633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 282N00000X | 000046 | TX | N | Hospitals | General Acute Care Hospital | 367500000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 282N00000X | 100322 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 119874903 | 05 | TX | MEDICAID | 119874904 | 05 | TX | MEDICAID | 119874905 | 05 | TX | MEDICAID | 119874902 | 05 | TX | MEDICAID | HH0054 | 01 | TX | BC/BS PROVIDER NUMBER | OTHER |