Provider Demographics
NPI:1952342149
Name:MT. ENTERPRISE COMMUNITY HEALTH CLINIC
Entity Type:Organization
Organization Name:MT. ENTERPRISE COMMUNITY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-822-3076
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:MT ENTERPRISE
Mailing Address - State:TX
Mailing Address - Zip Code:75681-0489
Mailing Address - Country:US
Mailing Address - Phone:903-822-3076
Mailing Address - Fax:903-822-3079
Practice Address - Street 1:106 WEST RUSK
Practice Address - Street 2:
Practice Address - City:MOUNT ENTERPRISE
Practice Address - State:TX
Practice Address - Zip Code:75681
Practice Address - Country:US
Practice Address - Phone:903-822-3076
Practice Address - Fax:903-822-3079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
671840Medicare UPIN
TXTXB129796Medicare UPIN