Provider Demographics
NPI:1528030285
Name:CHRISTUS HEALTH SOUTHEAST TEXAS
Entity Type:Organization
Organization Name:CHRISTUS HEALTH SOUTHEAST TEXAS
Other - Org Name:CHRISTUS SOUTHEAST TEXAS - FAMILY PRACTICE CENTER JASPER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-899-7102
Mailing Address - Street 1:PO BOX 848060
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8060
Mailing Address - Country:US
Mailing Address - Phone:800-756-7999
Mailing Address - Fax:469-282-1999
Practice Address - Street 1:1276 S PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4916
Practice Address - Country:US
Practice Address - Phone:409-384-5701
Practice Address - Fax:409-384-4238
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRISTUS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-06
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137305204Medicaid
TX137305204Medicaid