Provider Demographics
NPI:1639337488
Name:DEPT OF STATE HEALTH SERVICES WIC
Entity Type:Organization
Organization Name:DEPT OF STATE HEALTH SERVICES WIC
Other - Org Name:DSHS WIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PUBLIC HEALTH TECH III
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:WCS,CLC
Authorized Official - Phone:903-885-8022
Mailing Address - Street 1:1400 COLLEGE STREET
Mailing Address - Street 2:#167
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482
Mailing Address - Country:US
Mailing Address - Phone:903-885-8022
Mailing Address - Fax:903-439-9330
Practice Address - Street 1:1400 COLLEGE ST
Practice Address - Street 2:STE 167
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-3469
Practice Address - Country:US
Practice Address - Phone:903-885-8022
Practice Address - Fax:903-439-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherDEPARTMENT OF STATE HEALTH SERVICES - WIC