Provider Demographics
NPI:1891780656
Name:CHINA COMMUNITY CLINIC,LLC
Entity Type:Organization
Organization Name:CHINA COMMUNITY CLINIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/PAC
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:409-752-2301
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:TX
Mailing Address - Zip Code:77613-0786
Mailing Address - Country:US
Mailing Address - Phone:409-752-2301
Mailing Address - Fax:409-752-2301
Practice Address - Street 1:415 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:TX
Practice Address - Zip Code:77613
Practice Address - Country:US
Practice Address - Phone:409-752-2301
Practice Address - Fax:409-752-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2352207Q00000X
TXPA01495363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8H1480OtherMENDOZA BCBS #
TX8N3373OtherCHUCK HALL BCBS #
TX880660OtherBCBS # CLINIC
TX0033JQOtherCCC BCBS GROUP #
TX880660OtherBCBS # CLINIC
TX0033JQOtherCCC BCBS GROUP #
TXS61761Medicare UPIN
TX8H1480OtherMENDOZA BCBS #
TXC12207Medicare UPIN
TX85N737Medicare ID - Type UnspecifiedCHUCK HALL MCR #