NPIMap

Organization Active NPI

East Texas Border Health Clinic

Doing business as Genesis Primecare

  • Federally Qualified Health Center (FQHC)
  • Longview, TX
National Provider Identifier
1669872560
Registry record updated Aug 28, 2023
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
2131 S Mobberly Ave
Longview, TX 75602-3563
Phone
(903) 758-3551
NPI assigned
Aug 27, 2014
Last updated
Aug 28, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 28, 2023

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

2131 S Mobberly Ave
Longview, TX 75602-3563

Mailing address

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

Other names 1

  • GENESIS PRIMECARE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669872560. Details of each certification follow.

  • CCN 741865 Federally qualified health center · Active · Name & address match · Details

Federally qualified health center certification: CCN 741865

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
GENESIS PRIMECARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 29, 2014
Last certification
Oct 29, 2014
Ownership / control type
For profit – corporation
Facility address
2131 S Mobberly Ave
Longview, TX 75602

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

2131 S Mobberly Ave
Longview, TX 75602
Phone (903) 315-5750

NPI Registry JSON

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

{
    "created_epoch": "1409097600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1693180800000",
    "number": "1669872560",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2131 S MOBBERLY AVE",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "756023563",
            "telephone_number": "903-758-3551"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TEXAS BORDER HEALTH CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-08-27",
        "last_updated": "2023-08-28",
        "certification_date": "2023-08-28",
        "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",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "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 Longview, TX

Sources for this page

Verify at the official NPI Registry.