MEDICARE: HCMH RETAIL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1114399318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HCMH RETAIL CLINIC

Provider Business Mailing Address
First Line	:	1339 S BROADWAY ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-4895
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1339 S BROADWAY ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-4895
Country	:	US
Telephone Number	:	903-885-3181
Fax Number	:

Authorized Official
Title or Position	:	CMOM
Name	:	LAURA WILLIAMS
Credential	:
Telephone Number	:	903-438-3336

Provider Enumeration Date	:	10/27/2015
Last Update Date	:	10/29/2015

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Directions to “HCMH RETAIL CLINIC ” Practice Location

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