Healthcare Provider Details

I. General information

NPI: 1275713976
Provider Name (Legal Business Name): COMMUNITY HEALTH CLINICS OF NORTHEAST TEXAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 N GLENWOOD BLVD
TYLER TX
75702-5055
US

IV. Provider business mailing address

928 N GLENWOOD BLVD
TYLER TX
75702-5055
US

V. Phone/Fax

Practice location:
  • Phone: 903-526-4900
  • Fax: 903-526-4907
Mailing address:
  • Phone: 903-533-7400
  • Fax: 903-533-7409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRYAN F WILDER
Title or Position: CFO
Credential:
Phone: 903-533-7400