Provider Demographics
NPI:1215974688
Name:IRON MOUNTAIN MEDICAL CENTER LLC
Entity type:Organization
Organization Name:IRON MOUNTAIN MEDICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:HORNE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:936-348-9141
Mailing Address - Street 1:106 N GRACE ST
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-1722
Mailing Address - Country:US
Mailing Address - Phone:936-348-9141
Mailing Address - Fax:936-348-9143
Practice Address - Street 1:106 N GRACE ST
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1722
Practice Address - Country:US
Practice Address - Phone:936-544-7202
Practice Address - Fax:936-546-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0037RBOtherBCBS
TX138350710OtherPCP
TX0051BVOtherBCBS
TX092386401Medicaid
TX092386403Medicaid
TX092386403Medicaid