Healthcare Provider Details

I. General information

NPI: 1124121009
Provider Name (Legal Business Name): CANYON LAKE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 FM 2673
CANYON LAKE TX
78133-4510
US

IV. Provider business mailing address

1356 FM 2673
CANYON LAKE TX
78133-4510
US

V. Phone/Fax

Practice location:
  • Phone: 830-964-3019
  • Fax: 830-226-5002
Mailing address:
  • Phone: 830-964-3019
  • Fax: 830-226-5002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFF P MADISON
Title or Position: OWNER
Credential:
Phone: 512-446-4500