Healthcare Provider Details

I. General information

NPI: 1215205265
Provider Name (Legal Business Name): SHACKELFORD COUNTY COMMUNITY RESOURCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 NORTH ACCESS ROAD
CLYDE TX
79510
US

IV. Provider business mailing address

PO BOX 2435
ALBANY TX
76430-8020
US

V. Phone/Fax

Practice location:
  • Phone: 325-893-4010
  • Fax: 325-893-4035
Mailing address:
  • Phone: 325-762-2447
  • Fax: 325-762-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number30117281979
License Number StateTX

VIII. Authorized Official

Name: MRS. TINA LOUISE BETCHER
Title or Position: BILLING MANAGER/CREDENTIALER
Credential:
Phone: 325-893-4010