Provider Demographics
NPI:1184973216
Name:FRIENDLY NEIGHBORHOOD HEALTH CLINIC, PLLC
Entity type:Organization
Organization Name:FRIENDLY NEIGHBORHOOD HEALTH CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:TERESE
Authorized Official - Last Name:DITTBURNER
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:956-428-8264
Mailing Address - Street 1:617 E LOOP 499 STE C
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-2477
Mailing Address - Country:US
Mailing Address - Phone:956-428-8264
Mailing Address - Fax:956-425-3642
Practice Address - Street 1:617 E LOOP 499 STE C
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-2477
Practice Address - Country:US
Practice Address - Phone:956-428-8264
Practice Address - Fax:956-425-3642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX520212302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D5333Medicaid
TX8D5333Medicaid