Healthcare Provider Details

I. General information

NPI: 1861680886
Provider Name (Legal Business Name): CLYDE CONS ISD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 SHALIMAR
CLYDE TX
79510
US

IV. Provider business mailing address

526 SHALIMAR
CLYDE TX
79510
US

V. Phone/Fax

Practice location:
  • Phone: 325-893-4222
  • Fax:
Mailing address:
  • Phone: 325-893-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: DR. GALE HATERIUS
Title or Position: DIRECTOR
Credential:
Phone: 325-893-4222