=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467700112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY DUNDAS CLINIC(NO LONGER IN SERVICE)
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2012
-----------------------------------------------------
Last Update Date | 12/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 HOSPITAL DR STE 300
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77701-4635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-835-9300
-----------------------------------------------------
Fax | 713-523-4897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 66308
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77266-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-548-5076
-----------------------------------------------------
Fax | 713-523-4897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KATY CALDWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-548-5015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------