NPIMap

Organization Active NPI

East Texas Border Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Texarkana, TX
National Provider Identifier
1053663690
Registry record updated Jun 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EAST TEXAS BORDER HEALTH CLINIC
Practice address
1400 College Dr
Texarkana, TX 75503-3536
Phone
(903) 791-1110
Fax
(903) 791-9353
NPI assigned
Oct 5, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 2024

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

Authorized official

Name
Carla Roadcap
Title
Ceo
Phone
(903) 927-3782

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1400 College Dr
Texarkana, TX 75503-3536

Mailing address

PO Box 1326
Marshall, TX 75671-1326
Phone (903) 927-3782

Other identifiers 2

IdentifierTypeStateIssuer
192226202MedicaidTX
198049002MedicaidAR

Other names 1

  • Genesis PrimeCare Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050511001030 TX Part B Supplier - Clinic/Group Practice 8820038565 Receives reassigned benefits from 50 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Marshall, TX; Texarkana, TX; Atlanta, TX
O20130109000585 TX Part A Provider - Federally Qualified Health Center (FQHC) 8820038565 Practice locations: Texarkana, TX

Federally qualified health center certification: CCN 741811

Legal name
EAST TEXAS BORDER HEALTH CLINIC
Doing business as
GENESIS PRIMECARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 9, 2013
Last certification
Jan 9, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 15, 2004 in TX
Enrollment address
1400 College Dr
Texarkana, TX 75503-3534

Other NPIs with the same Medicare PAC ID 10

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

Other NPIs on the same Medicare enrollment 17

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

View all 17

National Provider Directory

National Provider Directory

Locations

1400 College Dr
Ste 204
Texarkana, TX 75503
Phone (903) 791-1110

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Kimberly Quiett Individual Corporate DirectorBoard of Director Member Oct 27, 2016
Carla Roadcap Individual Corporate OfficerCeo May 1, 2014
W-2 Managing EmployeeCeo May 1, 2014
Alana Higgins Individual Corporate DirectorBoard Member Jul 29, 2021
Marva Simpson Individual Corporate DirectorBoard of Director Member Feb 22, 2018
Michael G Boles Individual Corporate DirectorBoard Member Dec 20, 2012
Jeffory W Beaty Individual Corporate DirectorCmo Apr 12, 2012
Amanda Abraham Individual Corporate DirectorBoard Member Feb 27, 2025
Betty Yarber Individual Corporate DirectorBoard Member Feb 27, 2025
Ted David Huffhines Individual Corporate DirectorBoard Vice Chair Aug 25, 2022
Glenn Bickerdike Individual Corporate DirectorBoard Member Mar 31, 2025
Ruthie Smith Individual Corporate DirectorBoard of Director Member Jun 20, 2018
Julie Stowe Individual Corporate OfficerCfo Jan 23, 2013
W-2 Managing EmployeeCfo Jan 23, 2013
Stuart Smith Individual Corporate DirectorBoard Member Oct 27, 2016
Valarie a Allman Individual Corporate DirectorBoard Member Aug 25, 2022

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1349395200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718236800000",
    "number": "1053663690",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1326",
            "city": "MARSHALL",
            "state": "TX",
            "postal_code": "756711326",
            "telephone_number": "903-927-3782",
            "fax_number": "903-927-1764"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 COLLEGE DR",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "755033536",
            "telephone_number": "903-791-1110",
            "fax_number": "903-791-9353"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TEXAS BORDER HEALTH CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-05",
        "last_updated": "2024-06-13",
        "certification_date": "2024-06-13",
        "status": "A",
        "authorized_official_last_name": "ROADCAP",
        "authorized_official_first_name": "CARLA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "903-927-3782"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "192226202",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "198049002",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Genesis PrimeCare",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Genesis PrimeCare",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Texarkana, TX

Sources for this page

Verify at the official NPI Registry.