Provider Demographics
NPI:1477742856
Name:COMMUNITY HEALTH CLINICS OF NORTHEAST TEXAS
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CLINICS OF NORTHEAST TEXAS
Other - Org Name:TOTAL HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-533-7400
Mailing Address - Street 1:928 N GLENWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-5055
Mailing Address - Country:US
Mailing Address - Phone:903-533-7400
Mailing Address - Fax:903-533-7409
Practice Address - Street 1:928 N GLENWOOD BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5055
Practice Address - Country:US
Practice Address - Phone:903-533-7400
Practice Address - Fax:903-533-7409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190636401Medicaid
TX671907Medicare PIN