Provider Demographics
NPI:1982480323
Name:MCJV
Entity Type:Organization
Organization Name:MCJV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISAACS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-779-6093
Mailing Address - Street 1:614 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:614 ELM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-1714
Practice Address - Country:US
Practice Address - Phone:361-563-2966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center