Provider Demographics
NPI:1730472002
Name:FOURTH WARD CLINIC
Entity Type:Organization
Organization Name:FOURTH WARD CLINIC
Other - Org Name:GOOD NEIGHBOR HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:S
Authorized Official - Last Name:DONATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-529-3597
Mailing Address - Street 1:190 HEIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007
Mailing Address - Country:US
Mailing Address - Phone:713-529-3597
Mailing Address - Fax:713-529-9169
Practice Address - Street 1:8504 SCHULLER RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77093
Practice Address - Country:US
Practice Address - Phone:713-387-7171
Practice Address - Fax:713-387-7189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD NEIGHBOR - NORTH (SATELLITE)
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB106000OtherMEDICARE PTAN
TX67-1829OtherFQHC MEDICARE
TX126821105OtherFQHC MEDICAID