Provider Demographics
NPI:1366512139
Name:CHINA COMMUNITY CLINIC LLC
Entity type:Organization
Organization Name:CHINA COMMUNITY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:409-752-2301
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:TX
Mailing Address - Zip Code:77613-0786
Mailing Address - Country:US
Mailing Address - Phone:409-752-2301
Mailing Address - Fax:409-752-5054
Practice Address - Street 1:415 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:TX
Practice Address - Zip Code:77613
Practice Address - Country:US
Practice Address - Phone:409-752-2301
Practice Address - Fax:409-752-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC12207Medicare UPIN
TX00160UMedicare ID - Type Unspecified