Provider Demographics
NPI:1578545539
Name:COLLOM & CARNEY CLINIC ASSOCIATION
Entity Type:Organization
Organization Name:COLLOM & CARNEY CLINIC ASSOCIATION
Other - Org Name:NORTHEAST TEXAS DIALYSIS UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-614-3601
Mailing Address - Street 1:4800 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3033
Mailing Address - Country:US
Mailing Address - Phone:903-614-3600
Mailing Address - Fax:903-792-0951
Practice Address - Street 1:606 LOOP 59
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-1510
Practice Address - Country:US
Practice Address - Phone:903-614-3601
Practice Address - Fax:903-792-0951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000189261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149926734Medicaid
OK100702210CMedicaid
TX087889401Medicaid
AR149926734Medicaid