Provider Demographics
NPI:1003303983
Name:CROCKETT MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:CROCKETT MEDICAL CENTER, LLC
Other - Org Name:CROCKETT MEDICAL CENTER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:TJELMELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-617-7500
Mailing Address - Street 1:4220 BULL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6026
Mailing Address - Country:US
Mailing Address - Phone:512-617-7505
Mailing Address - Fax:
Practice Address - Street 1:1050 E LOOP 304 STE 201
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1814
Practice Address - Country:US
Practice Address - Phone:936-546-3890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health