Provider Demographics
NPI:1356663546
Name:COLORADO FAYETTE MEDICAL CENTER
Entity Type:Organization
Organization Name:COLORADO FAYETTE MEDICAL CENTER
Other - Org Name:FLATONIA COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-725-9531
Mailing Address - Street 1:P O BOX 909
Mailing Address - Street 2:113 W SOUTH MAIN STREET
Mailing Address - City:FLATONIA
Mailing Address - State:TX
Mailing Address - Zip Code:78941-2665
Mailing Address - Country:US
Mailing Address - Phone:361-865-3561
Mailing Address - Fax:361-865-3439
Practice Address - Street 1:113 W SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:FLATONIA
Practice Address - State:TX
Practice Address - Zip Code:78941-2665
Practice Address - Country:US
Practice Address - Phone:361-865-3561
Practice Address - Fax:361-865-3435
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO FAYETTE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-16
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000005282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX453405Medicare Oscar/Certification