Provider Demographics
NPI:1992763684
Name:DEWEYVILLE RURAL HEALTH CLINIC LLC
Entity type:Organization
Organization Name:DEWEYVILLE RURAL HEALTH CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:409-746-7000
Mailing Address - Street 1:2493 STATE HIGHWAY 12 E
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-8426
Mailing Address - Country:US
Mailing Address - Phone:409-746-7000
Mailing Address - Fax:409-746-7016
Practice Address - Street 1:2493 STATE HIGHWAY 12 E
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77632-8426
Practice Address - Country:US
Practice Address - Phone:409-746-7000
Practice Address - Fax:409-746-7016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10-560939-6261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170485001Medicaid
TX673876Medicare Oscar/Certification