MEDICARE: CONCHO COUNTY RURAL 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	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1972678142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCHO COUNTY RURAL HEALTH CLINIC

Provider Business Mailing Address
First Line	:	13 SOUTH MAIN STREET
Second Line	:	P.O. BOX 987
City	:	EDEN
State	:	TX
Zip	:	76837-0987
Country	:	US
Telephone Number	:	325-869-8811
Fax Number	:	325-869-8899

Provider Business Practice Location Address
First Line	:	13 SOUTH MAIN STREET
Second Line	:
City	:	EDEN
State	:	TX
Zip	:	76837-0987
Country	:	US
Telephone Number	:	325-869-8811
Fax Number	:	325-869-8899

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DUDLEY WHITE
Credential	:
Telephone Number	:	325-869-5911

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	08/22/2020

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