Provider Demographics
NPI:1851045595
Name:EAST TEXAS CLINIC INC
Entity Type:Organization
Organization Name:EAST TEXAS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:STALNAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-759-4966
Mailing Address - Street 1:PO BOX 9486
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-9486
Mailing Address - Country:US
Mailing Address - Phone:903-759-4966
Mailing Address - Fax:
Practice Address - Street 1:201 PINE TREE RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-4140
Practice Address - Country:US
Practice Address - Phone:903-759-4966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone