Provider Demographics
NPI:1053663690
Name:EAST TEXAS BORDER HEALTH CLINIC
Entity Type:Organization
Organization Name:EAST TEXAS BORDER HEALTH CLINIC
Other - Org Name:GENESIS PRIMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROADCAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-927-3782
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:903-927-3782
Mailing Address - Fax:903-927-1764
Practice Address - Street 1:1400 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3536
Practice Address - Country:US
Practice Address - Phone:903-791-1110
Practice Address - Fax:903-791-9353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192226202Medicaid
AR198049002Medicaid