Provider Demographics
NPI:1265613285
Name:COMMUNITY HEALTH CLINIC OF NORTHEAST TEXAS
Entity type:Organization
Organization Name:COMMUNITY HEALTH CLINIC OF NORTHEAST TEXAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA,MHA
Authorized Official - Phone:903-533-7404
Mailing Address - Street 1:815 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-4507
Mailing Address - Country:US
Mailing Address - Phone:903-535-0023
Mailing Address - Fax:903-535-0052
Practice Address - Street 1:928 N GLENWOOD BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5055
Practice Address - Country:US
Practice Address - Phone:903-533-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)