Provider Demographics
NPI:1285761999
Name:AIDS OUTREACH CENTER
Entity type:Organization
Organization Name:AIDS OUTREACH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELLISAND
Authorized Official - Middle Name:
Authorized Official - Last Name:LE ROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-335-1994
Mailing Address - Street 1:400 NORTH BEACH STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111
Mailing Address - Country:US
Mailing Address - Phone:817-335-1994
Mailing Address - Fax:817-335-3617
Practice Address - Street 1:400 NORTH BEACH STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111
Practice Address - Country:US
Practice Address - Phone:817-335-1994
Practice Address - Fax:817-335-3617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109329601Medicaid
TX109329602Medicaid
TXTXB112740OtherMEDICARE PTAN