Provider Demographics
NPI:1336590462
Name:PROVIDENCE HEALTH ALLIANCE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH ALLIANCE
Other - Org Name:PROVIDENCE FAMILY HEALTH CLINIC-HILLSBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-751-4172
Mailing Address - Street 1:6901 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7910
Mailing Address - Country:US
Mailing Address - Phone:254-751-4739
Mailing Address - Fax:
Practice Address - Street 1:6901 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7910
Practice Address - Country:US
Practice Address - Phone:254-751-4739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
458913Medicare PIN