Provider Demographics
NPI:1497568513
Name:EAST TEXAS COMMUNITY CLINIC, INC.
Entity type:Organization
Organization Name:EAST TEXAS COMMUNITY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-603-9851
Mailing Address - Street 1:PO BOX 1610
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-1610
Mailing Address - Country:US
Mailing Address - Phone:903-603-9851
Mailing Address - Fax:903-802-7125
Practice Address - Street 1:400 E STATE HIGHWAY 243 STE 18
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-2445
Practice Address - Country:US
Practice Address - Phone:903-287-5011
Practice Address - Fax:903-802-7125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TEXAS COMMUNITY CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)