Healthcare Provider Details

I. General information

NPI: 1033752456
Provider Name (Legal Business Name): EAST TEXAS COMMUNITY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAIN ST
GUN BARREL CITY TX
75156-5312
US

IV. Provider business mailing address

PO BOX 1610
ATHENS TX
75751-1610
US

V. Phone/Fax

Practice location:
  • Phone: 903-887-1011
  • Fax: 903-340-8410
Mailing address:
  • Phone: 903-603-9851
  • Fax: 903-802-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: GLEN W ROBISON
Title or Position: CEO
Credential:
Phone: 903-603-9851