Provider Demographics
NPI:1093936775
Name:ALICE OBGYN SPECIALTY CLINIC, PA
Entity Type:Organization
Organization Name:ALICE OBGYN SPECIALTY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:C
Authorized Official - Last Name:HASETTE
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:361-664-6671
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78333-0970
Mailing Address - Country:US
Mailing Address - Phone:361-664-6671
Mailing Address - Fax:361-664-6686
Practice Address - Street 1:2510 E MAIN ST
Practice Address - Street 2:SUITE 106
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4187
Practice Address - Country:US
Practice Address - Phone:361-664-6671
Practice Address - Fax:361-664-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6230174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH91773Medicare UPIN
TX00478XMedicare PIN