Healthcare Provider Details

I. General information

NPI: 1700100104
Provider Name (Legal Business Name): COLLOM & CARNEY CLINIC ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 N ELLIS ST
NEW BOSTON TX
75570-2904
US

IV. Provider business mailing address

5002 COWHORN CREEK RD
TEXARKANA TX
75503-9766
US

V. Phone/Fax

Practice location:
  • Phone: 903-628-1104
  • Fax: 903-628-0104
Mailing address:
  • Phone: 903-614-3000
  • Fax: 903-614-3525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY E DWIGHT
Title or Position: CHIEF OPERATING OFFICER
Credential: MHA, CCS-P, CMPE
Phone: 903-614-3282