Provider Demographics
NPI:1548649767
Name:MATAGORDA EPISCOPAL HEALTH OUTREACH PROGRAM
Entity type:Organization
Organization Name:MATAGORDA EPISCOPAL HEALTH OUTREACH PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING MANGER
Authorized Official - Prefix:
Authorized Official - First Name:MANUELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-245-2008
Mailing Address - Street 1:101 AVENUE F N
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-3167
Mailing Address - Country:US
Mailing Address - Phone:979-245-2008
Mailing Address - Fax:979-245-0744
Practice Address - Street 1:101 AVENUE F N
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-3167
Practice Address - Country:US
Practice Address - Phone:979-245-2008
Practice Address - Fax:979-245-0744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173656303Medicaid