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105 Fm 2342 Kingsland TX 78639-6010 | |
(325) 388-3515 | |
(325) 388-9422 |
Full Name | |
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Speciality | Clinic/Center |
Location | 105 Fm 2342, Kingsland, Texas |
Authorized Official Name and Position | Timothy Ols (CEO) |
Authorized Official Contact | 8302018679 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Po Box 844658 Dallas TX 75284-4339 Ph: (254) 724-2111 | 105 Fm 2342 Kingsland TX 78639-6010 Ph: (325) 388-3515 |
NPI Number | 1730480393 |
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Provider Enumeration Date | 11/12/2010 |
Last Update Date | 10/17/2019 |
Medicare PECOS PAC ID | 6901117175 |
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Medicare Enrollment ID | O20191014000212 |
Identifier | Type | State | Issuer |
---|---|---|---|
1730480393 | NPI | - | NPPES |
287274901 | Medicaid | TX | |
0042WF | Other | TX | BCBS |
287274902 | Other | TX | THSTEPS |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QR1300X | Clinic/center - Rural Health | 100090 (Texas) | Primary |