Healthcare Provider Details

I. General information

NPI: 1124296843
Provider Name (Legal Business Name): HEALTH OPPORTUNITIES FOR THE PEOPLE OF EAST TEXAS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 WALL STREET
TENAHA TX
75974-5413
US

IV. Provider business mailing address

PO BOX 1584
CENTER TX
75935-1584
US

V. Phone/Fax

Practice location:
  • Phone: 936-248-4673
  • Fax: 936-248-4646
Mailing address:
  • Phone: 936-591-8380
  • Fax: 936-598-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number221153
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number39493
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number541217
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number562803
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DESTANI DUTTON
Title or Position: CREDENTIALING/BILLING
Credential:
Phone: 936-591-8380