MEDICARE: CANYON LAKE MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0022HN	OTHER	TX	BLUE CROSS/BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124121009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON LAKE MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	1356 FM 2673
Second Line	:
City	:	CANYON LAKE
State	:	TX
Zip	:	78133-4510
Country	:	US
Telephone Number	:	830-964-3019
Fax Number	:	830-226-5002

Provider Business Practice Location Address
First Line	:	1356 FM 2673
Second Line	:
City	:	CANYON LAKE
State	:	TX
Zip	:	78133-4510
Country	:	US
Telephone Number	:	830-964-3019
Fax Number	:	830-226-5002

Authorized Official
Title or Position	:	OWNER
Name	:	JEFF P MADISON
Credential	:
Telephone Number	:	512-446-4500

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	08/25/2011

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Directions to “CANYON LAKE MEDICAL CLINIC ” Practice Location

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