NPIMap

Organization Active NPI

East Texas Border Health Clinic

Doing business as Genesis PrimeCare

  • Federally Qualified Health Center (FQHC)
  • Texarkana, AR
National Provider Identifier
1093186249
Registry record updated Dec 12, 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
Doing business as
Genesis PrimeCare
Practice address
1205 E 35TH St
Texarkana, AR 71854-2746
Phone
(870) 216-0080
Fax
(870) 216-0093
NPI assigned
Oct 14, 2015
Last updated
Dec 12, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 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 4

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Counselor 101Y00000X NU
Family Medicine Physician 207Q00000X NU
Pediatrics Physician 208000000X NU

Addresses

Primary practice location

1205 E 35TH St
Texarkana, AR 71854-2746

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
356940201MedicaidTX
213389749MedicaidAR

Other names 1

  • Genesis PrimeCare Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX, AR3 enrollments

Enrollment records 3

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
O20160203000828 AR Part A Provider - Federally Qualified Health Center (FQHC) 8820038565 Practice locations: Texarkana, AR
O20170629001989 AR Part B Supplier - Clinic/Group Practice 8820038565 Receives reassigned benefits from 21 practitioners
1 other NPI on this enrollment
Practice locations: Texarkana, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1093186249. Details of each certification follow.

Federally qualified health center certification: CCN 041912

Legal name
EAST TEXAS BORDER HEALTH CLINIC
Doing business as
GENESIS PRIMECARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 4, 2016
Last certification
Feb 4, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 15, 2004 in TX
Enrollment address
1205 East 35TH Street
Texarkana, AR 71854

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 18

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

View all 18

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2105446Genesis Primecare1205 East 35TH Street, Texarkana, AR 71854Certificate of waiverNov 23, 2027

National Provider Directory

National Provider Directory

Locations

4077 Jefferson Ave
Texarkana, AR 71854
Phone (870) 330-9200

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 Member Oct 27, 2016
Carla Roadcap Individual Corporate Officer Dec 9, 2015
W-2 Managing Employee Dec 9, 2015
Alana Higgins Individual Corporate DirectorBoard Member Jul 29, 2021
Marva Simpson Individual Corporate DirectorBoard Member Feb 22, 2018
Michael G Boles Individual Corporate Director Dec 9, 2015
Jeffory W Beaty Individual Corporate OfficerCmo 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 Member Aug 25, 2022
Glenn Bickerdike Individual Corporate DirectorBoard Member Mar 31, 2025
Ruthie Smith Individual Corporate DirectorBoard 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.

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 21

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 21

NPI Registry JSON

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

{
    "created_epoch": "1444780800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1733961600000",
    "number": "1093186249",
    "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": "1205 E 35TH ST",
            "city": "TEXARKANA",
            "state": "AR",
            "postal_code": "718542746",
            "telephone_number": "870-216-0080",
            "fax_number": "870-216-0093"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TEXAS BORDER HEALTH CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-14",
        "last_updated": "2024-12-12",
        "certification_date": "2024-12-12",
        "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": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "356940201",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "213389749",
            "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, AR

Sources for this page

Verify at the official NPI Registry.