Provider Demographics
NPI:1881101483
Name:STEPHEN F AUSTIN COMMUNITY HEALTH CENTER, INC
Entity type:Organization
Organization Name:STEPHEN F AUSTIN COMMUNITY HEALTH CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-824-1480
Mailing Address - Street 1:2360 GULF FWY S
Mailing Address - Street 2:STE 100C
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6448
Mailing Address - Country:US
Mailing Address - Phone:281-824-1480
Mailing Address - Fax:281-220-6407
Practice Address - Street 1:2360 GULF FWY S
Practice Address - Street 2:STE 100C
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6448
Practice Address - Country:US
Practice Address - Phone:281-824-1480
Practice Address - Fax:281-220-6407
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEPHEN F AUSTIN COMMUNITY HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-04
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2151249OtherCLIA
TX399363601Medicaid