Provider Demographics
NPI:1225059686
Name:HEALTH CENTER OF SOUTHEAST TEXAS
Entity Type:Organization
Organization Name:HEALTH CENTER OF SOUTHEAST TEXAS
Other - Org Name:HEALTH CENTER OF SOUTHEAST TEXAS-SHEPHERD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RACCIATO
Authorized Official - Suffix:
Authorized Official - Credentials:MSHA
Authorized Official - Phone:281-592-2224
Mailing Address - Street 1:307 N WILLIAM BARNETT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77327-4061
Mailing Address - Country:US
Mailing Address - Phone:281-592-2224
Mailing Address - Fax:281-592-2225
Practice Address - Street 1:307 N WILLIAM BARNETT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4061
Practice Address - Country:US
Practice Address - Phone:281-592-2224
Practice Address - Fax:281-592-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179566803Medicaid
TX179566801Medicaid
TX0044NHOtherBLUE CROSS/S GROUP NUMBER
TX179566802Medicaid
TX0044NHOtherBLUE CROSS/S GROUP NUMBER