Provider Demographics
NPI:1881632875
Name:GOODALL-WITCHER HEALTHCARE FOUNDATION
Entity Type:Organization
Organization Name:GOODALL-WITCHER HEALTHCARE FOUNDATION
Other - Org Name:MERIDIAN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:JR
Authorized Official - Credentials:CHE
Authorized Official - Phone:254-675-8322
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76665-0528
Mailing Address - Country:US
Mailing Address - Phone:254-435-2525
Mailing Address - Fax:254-435-6025
Practice Address - Street 1:9295 HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:TX
Practice Address - Zip Code:76665
Practice Address - Country:US
Practice Address - Phone:254-435-2525
Practice Address - Fax:254-435-6025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163479203Medicaid
TX163479204Medicaid
TX163479201Medicaid
TX163479204Medicaid