Provider Demographics
NPI:1417248824
Name:SHACKELFORD COUNTY COMMUNITY RESOURCE CENTER
Entity Type:Organization
Organization Name:SHACKELFORD COUNTY COMMUNITY RESOURCE CENTER
Other - Org Name:RESOURCECARE BRECKENRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER/CREDENTIALER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:BETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-893-4010
Mailing Address - Street 1:PO BOX 2435
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:TX
Mailing Address - Zip Code:76430-8020
Mailing Address - Country:US
Mailing Address - Phone:325-762-2447
Mailing Address - Fax:325-762-2186
Practice Address - Street 1:2802 W WALKER ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-4000
Practice Address - Country:US
Practice Address - Phone:254-559-7215
Practice Address - Fax:254-559-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30117281979261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171901504Medicaid
TX171901504Medicaid