Provider Demographics
NPI:1619274776
Name:TEXAS SPINE & JOINT HOSPITAL LONGVIEW CLINIC
Entity Type:Organization
Organization Name:TEXAS SPINE & JOINT HOSPITAL LONGVIEW CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:725 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5412
Mailing Address - Country:US
Mailing Address - Phone:903-525-3422
Mailing Address - Fax:903-525-3397
Practice Address - Street 1:725 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5412
Practice Address - Country:US
Practice Address - Phone:903-525-3422
Practice Address - Fax:903-525-3397
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEXAS SPINE & JOINT HOSPITAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-24
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH1021OtherBCBS
TX162459502Medicaid
TX162459501Medicaid
TX162459502Medicaid