Provider Demographics
NPI:1629378963
Name:COLLOM & CARNEY CLINIC ASSOCIATION
Entity Type:Organization
Organization Name:COLLOM & CARNEY CLINIC ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST ADMINISTRATOR OF PATIENT SERV
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DWIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-614-3282
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:4110 RICHMOND PL
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0001
Practice Address - Country:US
Practice Address - Phone:903-831-6312
Practice Address - Fax:903-838-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty