Provider Demographics
NPI:1942298823
Name:ST. CHRISTOPHER MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:ST. CHRISTOPHER MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DOLLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-684-3232
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL BEACH
Mailing Address - State:TX
Mailing Address - Zip Code:77650-1449
Mailing Address - Country:US
Mailing Address - Phone:409-684-3232
Mailing Address - Fax:409-684-3535
Practice Address - Street 1:1698 HIGHWAY 87
Practice Address - Street 2:
Practice Address - City:CRYSTAL BEACH
Practice Address - State:TX
Practice Address - Zip Code:77650
Practice Address - Country:US
Practice Address - Phone:409-684-3232
Practice Address - Fax:409-684-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID NUMBER
TX=========OtherTAX ID NUMBER