Healthcare Provider Details

I. General information

NPI: 1487669073
Provider Name (Legal Business Name): VIDOR COMMUNITY HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 HIGHWAY 12
VIDOR TX
77662-4016
US

IV. Provider business mailing address

PO BOX 2202
VIDOR TX
77670-2202
US

V. Phone/Fax

Practice location:
  • Phone: 409-769-7795
  • Fax: 409-769-8721
Mailing address:
  • Phone: 409-769-7795
  • Fax: 409-769-8721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number561872
License Number StateTX

VIII. Authorized Official

Name: LINDA J BOONE
Title or Position: PRESIDENT
Credential: APN
Phone: 409-769-7795