Provider Demographics
NPI:1386660744
Name:COMMUNITY MOTHER AND CHILD HEALTH CENTER
Entity Type:Organization
Organization Name:COMMUNITY MOTHER AND CHILD HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:361-570-1082
Mailing Address - Street 1:510 E RIO GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6033
Mailing Address - Country:US
Mailing Address - Phone:361-570-1083
Mailing Address - Fax:
Practice Address - Street 1:510 E RIO GRANDE ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6033
Practice Address - Country:US
Practice Address - Phone:361-570-1083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
TX208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0801377601Medicaid
TX00929KOtherDEACTIVATED
TXTXB111322Medicare PIN