MEDICARE: MT ENTERPRISE COMMUNITY HEALTH 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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1477383065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT ENTERPRISE COMMUNITY HEALTH CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 489
Second Line	:
City	:	MT ENTERPRISE
State	:	TX
Zip	:	75681-0489
Country	:	US
Telephone Number	:	903-822-3076
Fax Number	:	866-305-8303

Provider Business Practice Location Address
First Line	:	300 N HIGH ST
Second Line	:
City	:	HENDERSON
State	:	TX
Zip	:	75652-5908
Country	:	US
Telephone Number	:	903-392-8203
Fax Number	:	866-835-6516

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	BECKY ELDRIDGE
Credential	:
Telephone Number	:	903-822-3076

Provider Enumeration Date	:	08/07/2024
Last Update Date	:	08/07/2024

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