NPIMap

Organization Active NPI

Health Center of Southeast Texas

Doing business as Health Center of Southeast Texas - Liberty

  • Federally Qualified Health Center (FQHC)
  • Liberty, TX
National Provider Identifier
1043570567
Registry record updated Feb 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
HEALTH CENTER OF SOUTHEAST TEXAS
Doing business as
Health Center of Southeast Texas - Liberty
Practice address
1400 N Travis St
Liberty, TX 77575-3138
Phone
(936) 334-1185
NPI assigned
May 17, 2012
Last updated
Feb 21, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 21, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Steven Racciato
Title
Executive Director
Phone
(281) 592-2224

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Nurse Practitioner 363LF0000X NU
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

1400 N Travis St
Liberty, TX 77575-3138

Mailing address

307 N William Barnett Ave
Cleveland, TX 77327-4061
Phone (281) 592-2224

Other identifiers 5

IdentifierTypeStateIssuer
00W245OtherTXMEDICARE GROUP NUMBER
0044NHOtherTXBLUE CROSS/SHIELD GROUP NUMBER
179566801MedicaidTX
179566803MedicaidTX
179566802MedicaidTX

Other names 1

  • Health Center of Southeast Texas - Liberty Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20060223000543 TX Part B Supplier - Clinic/Group Practice 9739195041 Receives reassigned benefits from 22 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Cleveland, TX; Shepherd, TX; Livingston, TX; Liberty, TX; Dayton, TX
O20150402000455 TX Part A Provider - Federally Qualified Health Center (FQHC) 9739195041 Practice locations: Liberty, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043570567. Details of each certification follow.

Federally qualified health center certification: CCN 741886

Legal name
HEALTH CENTER OF SOUTHEAST TEXAS
Doing business as
HEALTH CENTER OF SOUTHEAST TEXAS - LIBERTY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 27, 2015
Last certification
Mar 27, 2015
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 14, 2005 in TX
Enrollment address
1400 N Travis St
Liberty, TX 77575-3138

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

204 W Park
Livingston, TX 77352
Phone (936) 327-4660

204 W Park
Ste 100
Livingston, TX 77352

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/FIDFAA

Ownership & related parties

All disclosed owners & managing parties 12

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Susan Bailes Individual Corporate DirectorBoard Member Jul 1, 2014
Ilona Molton Individual Corporate DirectorVice Chairman of the Board Oct 9, 2014
Walter Scott Lambert Individual Corporate DirectorBoard Chair Feb 1, 2024
Jennifer L Bergman Individual Corporate DirectorBoard Member Feb 1, 2016
Sherrell Wolfe Individual Corporate DirectorBoard Member Jul 1, 2014
Amalia Reddell Individual Corporate DirectorBoard Member Jul 1, 2014
Eisha Jones Individual Corporate DirectorTreasurer Mar 10, 2016
Andee Kesner Individual Corporate OfficerChief Executive Officer May 4, 2026
Corporate DirectorChief Executive Officer May 4, 2026
W-2 Managing EmployeeChief Executive Officer May 4, 2026
Amanda Brooks Individual Corporate DirectorBoard Member Jun 9, 2022
Magdalena Estrada Individual Corporate OfficerChief Executive Officer May 4, 2026
Corporate DirectorChief Executive Officer May 4, 2026
W-2 Managing EmployeeChief Executive Officer May 4, 2026
Kari Rhodes Individual Corporate DirectorBoard Member Oct 13, 2022
James Smith Individual Corporate DirectorSecretary Sep 12, 2019

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1337212800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708473600000",
    "number": "1043570567",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "307 N WILLIAM BARNETT AVE",
            "city": "CLEVELAND",
            "state": "TX",
            "postal_code": "773274061",
            "telephone_number": "281-592-2224",
            "fax_number": "281-592-2225"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 N TRAVIS ST",
            "city": "LIBERTY",
            "state": "TX",
            "postal_code": "775753138",
            "telephone_number": "936-334-1185"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HEALTH CENTER OF SOUTHEAST TEXAS",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-05-17",
        "last_updated": "2024-02-21",
        "certification_date": "2024-02-21",
        "status": "A",
        "authorized_official_last_name": "RACCIATO",
        "authorized_official_first_name": "STEVEN",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "281-592-2224",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP NUMBER",
            "identifier": "00W245",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/SHIELD GROUP NUMBER",
            "identifier": "0044NH",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "179566801",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "179566803",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "179566802",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Health Center of Southeast Texas - Liberty",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Health Center of Southeast Texas - Liberty",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Liberty, TX

Sources for this page

Verify at the official NPI Registry.