Provider Demographics
NPI:1033752456
Name:EAST TEXAS COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:EAST TEXAS COMMUNITY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-603-9851
Mailing Address - Street 1:PO BOX 1610
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-1610
Mailing Address - Country:US
Mailing Address - Phone:903-603-9851
Mailing Address - Fax:903-802-7125
Practice Address - Street 1:801 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-5312
Practice Address - Country:US
Practice Address - Phone:903-887-1011
Practice Address - Fax:903-340-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Single Specialty