Basic Information
| Provider Information | |||||||||
| NPI: | 1831720176 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMISTAD COMMUNITY HEALTH CENTER, INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1533 S BROWNLEE BLVD STE 100 | ||||||||
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| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784043131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842242 | ||||||||
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| Practice Location | |||||||||
| Address1: | 814 E MAIN AVE | ||||||||
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| City: | ROBSTOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783803135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2020 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEVOS | ||||||||
| AuthorizedOfficialFirstName: | CAROLE | ||||||||
| AuthorizedOfficialMiddleName: | DIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTING ADMINSTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5122807943 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 01/27/2020 | ||||||||
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 | PENDING | 05 | TX | MEDICAID |