Provider Demographics
NPI:1831661412
Name:SPECIAL HEALTH RESOURCES FOR TEXAS INCORPORATED
Entity Type:Organization
Organization Name:SPECIAL HEALTH RESOURCES FOR TEXAS INCORPORATED
Other - Org Name:INTEGRATED PEDIATRIC CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:NESVIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-234-0776
Mailing Address - Street 1:PO BOX 2709
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2709
Mailing Address - Country:US
Mailing Address - Phone:903-234-0776
Mailing Address - Fax:903-234-9769
Practice Address - Street 1:1911 GALLERIA OAKS DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4617
Practice Address - Country:US
Practice Address - Phone:903-792-0308
Practice Address - Fax:903-792-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)