Provider Demographics
NPI:1043741275
Name:MT. ENTERPRISE COMMUNITY HEALTH CLINIC
Entity Type:Organization
Organization Name:MT. ENTERPRISE COMMUNITY HEALTH CLINIC
Other - Org Name:CROSSROADS FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-822-3076
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:MT ENTERPRISE
Mailing Address - State:TX
Mailing Address - Zip Code:75681-0489
Mailing Address - Country:US
Mailing Address - Phone:903-729-3015
Mailing Address - Fax:903-729-2738
Practice Address - Street 1:4002 S LOOP 256 STE K
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8402
Practice Address - Country:US
Practice Address - Phone:903-729-3015
Practice Address - Fax:903-729-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)