Basic Information
| Provider Information | |||||||||
| NPI: | 1861880080 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART OF TEXAS COMMUNITY HEALTH CENTER, INC | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MACARTHUR PEDIATRIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 MACARTHUR DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767083161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134326 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2014 | ||||||||
| LastUpdateDate: | 07/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | BALLEW | ||||||||
| AuthorizedOfficialFirstName: | ANNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2543134282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 345098301 | 05 | TX | MEDICAID |