=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942298823
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. CHRISTOPHER MEDICAL CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1698 HIGHWAY 87
-----------------------------------------------------
City | CRYSTAL BEACH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-684-3232
-----------------------------------------------------
Fax | 409-684-3535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1449
-----------------------------------------------------
City | CRYSTAL BEACH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77650-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-684-3232
-----------------------------------------------------
Fax | 409-684-3535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. DOLLY R DARIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 409-684-3232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------