Provider Demographics
NPI:1912060526
Name:EAST TEXAS MEDICAL CENTER TRINITY
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER TRINITY
Other - Org Name:COMMUNITY HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-546-3862
Mailing Address - Street 1:317 PROSPECT
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:TX
Mailing Address - Zip Code:75862
Mailing Address - Country:US
Mailing Address - Phone:936-594-3541
Mailing Address - Fax:936-546-3816
Practice Address - Street 1:317 PROSPECT
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:TX
Practice Address - Zip Code:75862
Practice Address - Country:US
Practice Address - Phone:936-594-3541
Practice Address - Fax:936-546-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1218174505Medicaid