Provider Demographics
NPI:1760496442
Name:BRENHAM CLINIC ASSN
Entity Type:Organization
Organization Name:BRENHAM CLINIC ASSN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SLATTERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-836-6153
Mailing Address - Street 1:600 NORTH PARK ST
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-2610
Mailing Address - Country:US
Mailing Address - Phone:979-836-6153
Mailing Address - Fax:
Practice Address - Street 1:600 NORTH PARK ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-2610
Practice Address - Country:US
Practice Address - Phone:979-836-6153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0498452291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137248412Medicaid
TX137248412Medicaid