Provider Demographics
NPI:1649412354
Name:MT. ENTERPRISE COMMUNITY HEALTH CLINIC
Entity Type:Organization
Organization Name:MT. ENTERPRISE COMMUNITY HEALTH CLINIC
Other - Org Name:CROSSROADS FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-822-3076
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:MOUNT ENTERPRISE
Mailing Address - State:TX
Mailing Address - Zip Code:75681-0489
Mailing Address - Country:US
Mailing Address - Phone:903-822-3076
Mailing Address - Fax:903-822-3079
Practice Address - Street 1:1115 HIGHWAY 259 SOUTH
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75654
Practice Address - Country:US
Practice Address - Phone:903-822-3076
Practice Address - Fax:903-822-3079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MT. ENTERPRISE COMMUNITY HEALTH CLINIC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-26
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203375502Medicaid
TX203375501Medicaid
TX203375501Medicaid