Basic Information
| Provider Information | |||||||||
| NPI: | 1184607723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH SERVICE AGENCY, INC. | ||||||||
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| OtherOrganizationName: | BONHAM MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1908 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754031908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034555986 | ||||||||
| FaxNumber: | 9034544621 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 E 6TH ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754184094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035836155 | ||||||||
| FaxNumber: | 9035833158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9034555986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 019055501 | 05 | TX | MEDICAID |