Provider Demographics
NPI:1902851728
Name:SAN JACINTO FAMILY PRACTICE EDUCATION FOUNDATION
Entity Type:Organization
Organization Name:SAN JACINTO FAMILY PRACTICE EDUCATION FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-420-8502
Mailing Address - Street 1:4301 GARTH RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-3153
Mailing Address - Country:US
Mailing Address - Phone:281-420-8400
Mailing Address - Fax:281-420-8445
Practice Address - Street 1:4301 GARTH RD
Practice Address - Street 2:SUITE 400
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-3153
Practice Address - Country:US
Practice Address - Phone:281-420-8400
Practice Address - Fax:281-420-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091752801Medicaid
TX091752802OtherEPSDT
TX091752802OtherEPSDT