Provider Demographics
NPI:1093982290
Name:KILGORE LIFE CENTER
Entity type:Organization
Organization Name:KILGORE LIFE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-247-0484
Mailing Address - Street 1:4002 TECHNOLOGY CTR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2697
Mailing Address - Country:US
Mailing Address - Phone:903-247-0484
Mailing Address - Fax:903-247-0485
Practice Address - Street 1:1711 S HENDERSON BLVD STE 300
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3563
Practice Address - Country:US
Practice Address - Phone:903-984-2145
Practice Address - Fax:903-984-8361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYNET, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-15
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159694201Medicaid
TX00468VMedicare PIN