Provider Demographics
NPI:1730182585
Name:FORT WORTH NORTHSIDE COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:FORT WORTH NORTHSIDE COMMUNITY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MSSW
Authorized Official - Phone:817-378-0855
Mailing Address - Street 1:2100 N MAIN ST
Mailing Address - Street 2:STE 215
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76106-8576
Mailing Address - Country:US
Mailing Address - Phone:817-378-0855
Mailing Address - Fax:817-378-0861
Practice Address - Street 1:2106 N. MAIN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106-8570
Practice Address - Country:US
Practice Address - Phone:817-625-4254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable