Provider Demographics
NPI:1487669073
Name:VIDOR COMMUNITY HEALTH CLINIC INC
Entity Type:Organization
Organization Name:VIDOR COMMUNITY HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:409-769-7795
Mailing Address - Street 1:PO BOX 2202
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77670-2202
Mailing Address - Country:US
Mailing Address - Phone:409-769-7795
Mailing Address - Fax:409-769-8721
Practice Address - Street 1:1290 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-4016
Practice Address - Country:US
Practice Address - Phone:409-769-7795
Practice Address - Fax:409-769-8721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX561872363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00037HOtherMEDICARE PART B
TX119735203Medicaid
TXRU0016OtherBCBS
TX119735203Medicaid