Provider Demographics
NPI:1396976478
Name:FRONTERA HEALTHCARE NETWORK, INC.
Entity type:Organization
Organization Name:FRONTERA HEALTHCARE NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER FRONTERA HE
Authorized Official - Prefix:MR
Authorized Official - First Name:CAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIBRINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-869-5500
Mailing Address - Street 1:P.O. BOX 989
Mailing Address - Street 2:604 EAKER ST.
Mailing Address - City:EDEN
Mailing Address - State:TX
Mailing Address - Zip Code:76837-0989
Mailing Address - Country:US
Mailing Address - Phone:325-869-5500
Mailing Address - Fax:325-869-5692
Practice Address - Street 1:108 SAN SABA AVE.
Practice Address - Street 2:
Practice Address - City:MENARD
Practice Address - State:TX
Practice Address - Zip Code:76859-0889
Practice Address - Country:US
Practice Address - Phone:325-396-2417
Practice Address - Fax:325-396-2417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24123261QD0000X, 261QF0400X
TX0026306261QF0400X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2109480Medicaid