Provider Demographics
NPI:1487707923
Name:BRAZOS MATERNAL AND CHILD HEALTH CLINIC, INC.
Entity type:Organization
Organization Name:BRAZOS MATERNAL AND CHILD HEALTH CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:CLARY
Authorized Official - Last Name:YEAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-595-1783
Mailing Address - Street 1:3370 S TEXAS AVE
Mailing Address - Street 2:STE G
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3127
Mailing Address - Country:US
Mailing Address - Phone:979-595-1780
Mailing Address - Fax:979-595-1777
Practice Address - Street 1:3370 S TEXAS AVE
Practice Address - Street 2:STE G
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3127
Practice Address - Country:US
Practice Address - Phone:979-595-1780
Practice Address - Fax:979-595-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1272205-04Medicaid
TX1272205-03Medicaid