Provider Demographics
NPI:1548745383
Name:EAST TEXAS BORDER HEALTH CLINIC
Entity Type:Organization
Organization Name:EAST TEXAS BORDER HEALTH CLINIC
Other - Org Name:GENESIS PRIMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROADCAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-927-3782
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:903-927-3782
Mailing Address - Fax:
Practice Address - Street 1:4077 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1509
Practice Address - Country:US
Practice Address - Phone:903-614-5270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TEXAS BORDER HEALTH CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-27
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty