Provider Demographics
NPI:1467700112
Name:LEGACY DUNDAS CLINIC(NO LONGER IN SERVICE)
Entity Type:Organization
Organization Name:LEGACY DUNDAS CLINIC(NO LONGER IN SERVICE)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-548-5015
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:832-548-5076
Mailing Address - Fax:713-523-4897
Practice Address - Street 1:810 HOSPITAL DR STE 300
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4635
Practice Address - Country:US
Practice Address - Phone:409-835-9300
Practice Address - Fax:713-523-4897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)