Provider Demographics
NPI:1255304101
Name:EAST TEXAS MEDICAL CENTER GRAPELAND RURAL HEALTH CLINIC
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER GRAPELAND RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:BAILEY
Authorized Official - Last Name:DISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-546-3862
Mailing Address - Street 1:PO BOX 1129
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-1129
Mailing Address - Country:US
Mailing Address - Phone:936-546-3849
Mailing Address - Fax:936-546-3816
Practice Address - Street 1:605 N MARKET ST
Practice Address - Street 2:
Practice Address - City:GRAPELAND
Practice Address - State:TX
Practice Address - Zip Code:75844-2129
Practice Address - Country:US
Practice Address - Phone:936-687-5986
Practice Address - Fax:936-687-5987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX458837Medicare ID - Type Unspecified