NPIMap

Organization Active NPI

Kilgore Life Center

  • Health Service Clinic/Center
  • Kilgore, TX
National Provider Identifier
1093982290
Registry record updated Sep 2, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Health Service Clinic/CenterTaxonomy code 261QH0100X
Legal business name
KILGORE LIFE CENTER
Practice address
1711 S Henderson Blvd Ste 300
Kilgore, TX 75662-3563
Phone
(903) 984-2145
Fax
(903) 984-8361
NPI assigned
May 15, 2008
Last updated
Sep 2, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PHYNET, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 2, 2025

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

Authorized official

Name
Mr. John D. Ford
Title
President
Phone
(903) 247-0484

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Health Service Clinic/Center 261QH0100X Primary

Addresses

Primary practice location

1711 S Henderson Blvd Ste 300
Kilgore, TX 75662-3563

Mailing address

4002 Technology Ctr
Longview, TX 75605-2697
Phone (903) 247-0484

Other identifiers 1

IdentifierTypeStateIssuer
159694201MedicaidTX

Other names 1

  • PhyNet, Inc. Other name

National Provider Directory

National Provider Directory
Tax ID family
Kilgore Life Center10 organizations share this tax ID, including this one
Part of
Kilgore Life Center

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

316 N Henderson Blvd
#A
Kilgore, TX 75662
Phone (903) 984-2145

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1210809600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1756771200000",
    "number": "1093982290",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4002 TECHNOLOGY CTR",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "756052697",
            "telephone_number": "903-247-0484",
            "fax_number": "903-247-0485"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1711 S HENDERSON BLVD STE 300",
            "city": "KILGORE",
            "state": "TX",
            "postal_code": "756623563",
            "telephone_number": "903-984-2145",
            "fax_number": "903-984-8361"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KILGORE LIFE CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PHYNET, INC.",
        "enumeration_date": "2008-05-15",
        "last_updated": "2025-09-02",
        "certification_date": "2025-03-19",
        "status": "A",
        "authorized_official_last_name": "FORD",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "D.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "903-247-0484",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "159694201",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PhyNet, Inc.",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Kilgore, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 2, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.