Provider Demographics
NPI:1104336072
Name:FIRST CLASS ACTIVITY CENTER, LLC
Entity type:Organization
Organization Name:FIRST CLASS ACTIVITY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-356-4265
Mailing Address - Street 1:PO BOX 1877
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78333-1877
Mailing Address - Country:US
Mailing Address - Phone:361-661-2727
Mailing Address - Fax:
Practice Address - Street 1:308 E 2ND STREET
Practice Address - Street 2:SUITE A
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4826
Practice Address - Country:US
Practice Address - Phone:361-356-4265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001030081Medicaid