Basic Information
Provider Information | |||||||||
NPI: | 1912308099 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNIUTY ACTION CORPORATION OF SOUTH TEXAS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY ACTION HEALTH CENTER KINGSVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 204 E 1ST ST | ||||||||
Address2: |   | ||||||||
City: | ALICE | ||||||||
State: | TX | ||||||||
PostalCode: | 783324822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3613960370 | ||||||||
FaxNumber: | 3616642248 | ||||||||
Practice Location | |||||||||
Address1: | 1311 GENERAL CAVAZOS BLVD | ||||||||
Address2: | SUITES 303 AND C | ||||||||
City: | KINGSVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 783637150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3615923237 | ||||||||
FaxNumber: | 3615923264 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2014 | ||||||||
LastUpdateDate: | 10/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AWALT | ||||||||
AuthorizedOfficialFirstName: | ANN | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3616640145 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUITY ACTION CORPORATION OF SOUTH TEXAS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.