Provider Demographics
NPI:1164273504
Name:AMISTAD COMMUNITY HEALTH CENTER, INCORPORATED
Entity Type:Organization
Organization Name:AMISTAD COMMUNITY HEALTH CENTER, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:DEVOS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:512-692-4010
Mailing Address - Street 1:1533 S BROWNLEE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-3131
Mailing Address - Country:US
Mailing Address - Phone:361-884-2242
Mailing Address - Fax:
Practice Address - Street 1:3602 MCARDLE RD RM WRM2
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-2623
Practice Address - Country:US
Practice Address - Phone:361-299-7056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)