Basic Information
| Provider Information | |||||||||
| NPI: | 1821475575 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH SERVICE AGENCY, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC CENTER OF GREENVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 3005 JOE RAMSEY BLVD E STE A | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754017776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034554458 | ||||||||
| FaxNumber: | 9034551604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2015 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9034555986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH SERVICE AGENCY, INC | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 368577801 | 05 | TX | MEDICAID |