Healthcare Provider Details

I. General information

NPI: 1922532555
Provider Name (Legal Business Name): EAST TEXAS BORDER HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S GROVE ST STE 105
MARSHALL TX
75670-5295
US

IV. Provider business mailing address

PO BOX 1326
MARSHALL TX
75671-1326
US

V. Phone/Fax

Practice location:
  • Phone: 903-935-9441
  • Fax:
Mailing address:
  • Phone: 903-927-3782
  • Fax: 903-927-1764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CARLA ROADCAP
Title or Position: CEO
Credential:
Phone: 903-927-3782