Provider Demographics
NPI:1093186249
Name:EAST TEXAS BORDER HEALTH CLINIC
Entity type:Organization
Organization Name:EAST TEXAS BORDER HEALTH CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROADCAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-927-3782
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:903-927-3782
Mailing Address - Fax:903-927-1764
Practice Address - Street 1:1205 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2746
Practice Address - Country:US
Practice Address - Phone:870-216-0080
Practice Address - Fax:870-216-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR213389749Medicaid
TX356940201Medicaid