Provider Demographics
NPI:1043570567
Name:HEALTH CENTER OF SOUTHEAST TEXAS
Entity Type:Organization
Organization Name:HEALTH CENTER OF SOUTHEAST TEXAS
Other - Org Name:HEALTH CENTER OF SOUTHEAST TEXAS - LIBERTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RACCIATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-592-2224
Mailing Address - Street 1:307 N WILLIAM BARNETT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77327-4061
Mailing Address - Country:US
Mailing Address - Phone:281-592-2224
Mailing Address - Fax:281-592-2225
Practice Address - Street 1:1400 N TRAVIS ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3138
Practice Address - Country:US
Practice Address - Phone:936-334-1185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179566802Medicaid
TX179566803Medicaid
TX179566801Medicaid
TX0044NHOtherBLUE CROSS/SHIELD GROUP NUMBER
TX00W245OtherMEDICARE GROUP NUMBER