East Texas Community Clinic, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Canton, TX
NPI 1497568513 · NPPES record last updated Jan 31, 2025
Key facts
- NPI
- 1497568513
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- EAST TEXAS COMMUNITY CLINIC, INC.
- Practice address
- 400 E State Highway 243 Ste 18
Canton, TX 75103-2445 - Phone
- (903) 287-5011
- Fax
- (903) 802-7125
- NPI assigned
- Jan 31, 2025
- Organization subpart
- Yes
- Parent organization (as reported)
- EAST TEXAS COMMUNITY CLINIC, INC.
Authorized official
- Name
- Glen W Robison
- Title
- Ceo
- Phone
- (903) 603-9851
Owners & managing parties with NPI records 1
-
Douglas W Curran, MD
Owned or controlled facilities with NPI records 1
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 1
Corporate family (same tax ID) 1
Practitioners 28
-
Douglas W Curran, MD
-
Jonathan Charles David, D.O.
-
Richard T David, MD
-
Victoria Marie Grounds, P.A.
-
Charles Ted Mettetal, M.D.
-
James Pittman, MD
-
Ronald W Heine, M.D.
-
Angela Marie Hill, FNP-C
-
Paul Stewart, FNP-C
-
Bruce Woodall, MD
-
Monica Cruz-Guel, NP
-
Richard Allen Lawson Jr., APRN
-
Linda Mercado, APRN-BC
-
Jordan Montoya, FNP
-
Dawn Janelle Pastor, FNP
-
Elizabeth Quiroga, FNP-C
-
Rocio Reyna, APRN, FNP-C
-
Jessica Maria Scarf, APRN
-
Jenny Vong, MSN, FNP-C
-
Talitha Bates, NP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TX
Federally qualified health center certification: CCN 971071
- Legal name
- EAST TEXAS COMMUNITY CLINIC INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Aug 13, 2025
- Last certification
- Aug 13, 2025
- Ownership / control type
- For profit – corporation
- Organization structure
- Other · Non-profit
- Enrollment address
- 400 E State Highway 243
Canton, TX 75103-2443
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Shelly Robertson |
Corporate Director |
Nov 12, 2019 | |
| Fagelyn Self |
Corporate Director |
Nov 12, 2019 | |
| Carla Smalley |
Corporate Director |
Nov 12, 2019 | |
| Pamela Woods |
Corporate Director |
Nov 12, 2019 | |
| Wesley Knight |
Corporate Director |
Nov 12, 2019 | |
| Amelia Hernandez |
Corporate Director |
Jan 22, 2024 | |
| Steven M Schiff |
Corporate Director |
Nov 12, 2019 | |
| Douglas Curran |
Corporate Officer |
Aug 1, 2019 | |
| W-2 Managing Employee |
Aug 1, 2019 | ||
| Mark Smith |
Corporate Director |
Nov 12, 2019 | |
| Glen Robison |
Corporate Officer |
Aug 1, 2019 | |
| W-2 Managing Employee |
Aug 1, 2019 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| East Texas Community Clinic, Inc. |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Jul 19, 2019 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20200407002337 | TX | Part B Supplier - Clinic/Group Practice | 3678902905 |
Receives reassigned benefits from 11 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Athens, TX; Canton, TX; Gun Barrel City, TX |
| O20250818001223 | TX | Part a Provider - Federally Qualified Health Center (FQHC) | 3678902905 | Practice locations: Canton, TX |
National Provider Directory
- Tax ID family
- East Texas Community Clinic
- Part of
- East Texas Community Clinic
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
400 E State Highway 243 Ste 18
Canton, TX 75103-2445
Mailing address
PO Box 1610
Athens, TX 75751-1610
Phone (903) 603-9851
Other names
- East Texas Community Clinic, Inc.
Other providers in Canton, TX
- Diverse Care Clinic of Canton PLLC
- Emily Ann Dosier
- Mark Dresselhouse
- Roseanna Lea Durnell
- Tara Lyn Duty
- Jan Lynne Eiland
- Sandra Saladino Embry
- Chelsea Emmert
- Euphoria Pediatric & Family Wellness, PLLC
- Leslea Evans
All providers in Canton, TX · Federally Qualified Health Center (FQHC) in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 31, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.