=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205218542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ON GUARD COMMUNITY HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2015
-----------------------------------------------------
Last Update Date | 06/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 W JACKSON ST STE 2
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-313-6305
-----------------------------------------------------
Fax | 888-508-2901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 W JACKSON ST STE 2
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-313-6305
-----------------------------------------------------
Fax | 888-508-2901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | CIGIA ROBBINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-313-6305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | H5050
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------