Healthcare Provider Details

I. General information

NPI: 1740720705
Provider Name (Legal Business Name): SAM RAYBURN VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E 9TH ST
BONHAM TX
75418-4059
US

IV. Provider business mailing address

1201 E 9TH ST
BONHAM TX
75418-4059
US

V. Phone/Fax

Practice location:
  • Phone: 903-583-1304
  • Fax:
Mailing address:
  • Phone: 903-583-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberDT84636
License Number StateTX

VIII. Authorized Official

Name: KATHERINE FLOYD
Title or Position: CLINICAL DIETITIAN
Credential: R.D.
Phone: 903-583-1304