Provider Demographics
NPI:1073904702
Name:CARDINAL COMMUNITY CLINIC
Entity Type:Organization
Organization Name:CARDINAL COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPERIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-880-8978
Mailing Address - Street 1:4400 MLK BOULEVARD
Mailing Address - Street 2:PO 10034
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77710-0000
Mailing Address - Country:US
Mailing Address - Phone:409-880-7681
Mailing Address - Fax:409-880-2263
Practice Address - Street 1:4400 MLK BOULEVARD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77710-0000
Practice Address - Country:US
Practice Address - Phone:409-880-7681
Practice Address - Fax:409-880-2263
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAMAR UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-17
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty