Provider Demographics
NPI:1164176749
Name:BEACON INTEGRATED HEALTHCARE
Entity Type:Organization
Organization Name:BEACON INTEGRATED HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:D
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:903-417-5377
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:TX
Mailing Address - Zip Code:75559-0369
Mailing Address - Country:US
Mailing Address - Phone:903-417-5377
Mailing Address - Fax:
Practice Address - Street 1:118 WOOD ST OFC 1
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:TX
Practice Address - Zip Code:75559-2112
Practice Address - Country:US
Practice Address - Phone:903-417-5377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATIENT ACCESS FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health