Basic Information
| Provider Information | |||||||||
| NPI: | 1104485374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH SERVICE AGENCY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1908 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754031908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034543025 | ||||||||
| FaxNumber: | 9034501408 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 CULVER ST | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754283608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034543025 | ||||||||
| FaxNumber: | 9034501408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9034555986 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH SERVICE AGENCY, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.