Basic Information
| Provider Information | |||||||||
| NPI: | 1871590653 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCHILTREE HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PERRYTON HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 GARRETT DR | ||||||||
| Address2: | |||||||||
| City: | PERRYTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790705323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064353606 | ||||||||
| FaxNumber: | 8064352813 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 GARRETT DR | ||||||||
| Address2: | |||||||||
| City: | PERRYTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790705323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064357224 | ||||||||
| FaxNumber: | 8064352813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JUDICE | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | PAIGE | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 8064353606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 98 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 092107401 | 05 | TX | MEDICAID | 0097ES | 01 | TX | BLUE CROSS | OTHER | 092107402 | 05 | TX | MEDICAID | 101618100 | 01 | FIRSTCARE | OTHER | 070837201 | 05 | TX | MEDICAID |