Provider Demographics
NPI:1184942799
Name:SHACKELFORD COUNTY HEALTH CLINIC
Entity type:Organization
Organization Name:SHACKELFORD COUNTY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SCHD ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-762-3661
Mailing Address - Street 1:PO BOX 2470
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:TX
Mailing Address - Zip Code:76430
Mailing Address - Country:US
Mailing Address - Phone:325-762-3661
Mailing Address - Fax:325-762-3859
Practice Address - Street 1:450 KENSHALO ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:TX
Practice Address - Zip Code:76430-3218
Practice Address - Country:US
Practice Address - Phone:325-762-3661
Practice Address - Fax:325-762-3859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10135791OtherUNITED HEALTHCARE
TX0071TQOtherBCBS
TX220311901Medicaid