Provider Demographics
NPI:1043209919
Name:SPECIAL HEALTH RESOURCES FOR TEXAS, INCORPORATED
Entity Type:Organization
Organization Name:SPECIAL HEALTH RESOURCES FOR TEXAS, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAUN'TA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-234-0776
Mailing Address - Street 1:PO BOX 2709
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2709
Mailing Address - Country:US
Mailing Address - Phone:903-234-0776
Mailing Address - Fax:903-234-9769
Practice Address - Street 1:410 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6511
Practice Address - Country:US
Practice Address - Phone:903-234-0776
Practice Address - Fax:903-234-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
TX261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0848160-01Medicaid
TX00R53ZMedicare PIN