Provider Demographics
NPI:1104065481
Name:PALACIOS MEDICAL CLINIC
Entity type:Organization
Organization Name:PALACIOS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:O
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-972-2511
Mailing Address - Street 1:311 GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:PALACIOS
Mailing Address - State:TX
Mailing Address - Zip Code:77465-3213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1519 4TH ST
Practice Address - Street 2:
Practice Address - City:PALACIOS
Practice Address - State:TX
Practice Address - Zip Code:77465-3203
Practice Address - Country:US
Practice Address - Phone:361-972-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALACIOS COMMUNITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000574261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health