Provider Demographics
NPI:1700192085
Name:NORTH TEXAS AREA COMMUNITY HEALTH CENTERS, INC
Entity Type:Organization
Organization Name:NORTH TEXAS AREA COMMUNITY HEALTH CENTERS, INC
Other - Org Name:SOUTHEAST COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GERRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-625-4254
Mailing Address - Street 1:2332 BEVERLY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114-1756
Mailing Address - Country:US
Mailing Address - Phone:817-625-4254
Mailing Address - Fax:817-378-0861
Practice Address - Street 1:2909 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-4642
Practice Address - Country:US
Practice Address - Phone:817-916-4333
Practice Address - Fax:817-916-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
TX516819261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX671949Medicare Oscar/Certification