NPIMap

Organization Active NPI

Special Health Resources for Texas, Inc.

Doing business as Med Plaza

  • Federally Qualified Health Center (FQHC)
  • Longview, TX
National Provider Identifier
1750769238
Registry record updated Jan 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SPECIAL HEALTH RESOURCES FOR TEXAS, INC.
Doing business as
Med Plaza
Practice address
703 E Marshall Ave
Suite 310
Longview, TX 75601-5500
Phone
(603) 234-8611
Fax
(903) 758-2283
NPI assigned
May 15, 2015
Last updated
Jan 20, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
SPECIAL HEALTH RESOURCES FOR TEXAS, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 20, 2023

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

Authorized official

Name
Mr. Kim Nesvig
Title
Executive Director
Phone
(903) 234-0776

Specialties & licenses 1

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

Addresses

Primary practice location

703 E Marshall Ave
Suite 310
Longview, TX 75601-5500

Mailing address

PO Box 2709
Longview, TX 75606-2709
Phone (903) 234-0776

Other names 1

  • MED PLAZA Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040623001434 TX Part B Supplier - Clinic/Group Practice 1355326158 Receives reassigned benefits from 22 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Texarkana, TX; Tyler, TX; Paris, TX; Longview, TX; Jacksonville, TX
O20150908001240 TX Part A Provider - Federally Qualified Health Center (FQHC) 1355326158 Practice locations: Longview, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1750769238. Details of each certification follow.

Federally qualified health center certification: CCN 741901

Legal name
SPECIAL HEALTH RESOURCES FOR TEXAS, INCORPORATED
Doing business as
MED PLAZA CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 4, 2015
Last certification
Sep 4, 2015
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 10, 1991 in TX
Enrollment address
703 East Marshall Avenue
Longview, TX 75601-5500

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 7

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

National Provider Directory

National Provider Directory
Tax ID family
Special Health Resources for Texas Inc11 organizations share this tax ID, including this one
Part of
Special Health Resources for Texas Inc

Other organizations with this tax ID 10

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

Locations

703 E Marshall Ave
Ste 310
Longview, TX 75601
Phone (603) 234-8611

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Roger Gardner Individual Corporate DirectorBoard Member Jun 25, 2019
Danny Rivers Individual Corporate DirectorBoard Treasurer May 29, 2018
Pamela Lewis Individual Corporate DirectorBoard Member Jun 30, 2020
Shaun'Ta Whitehead Individual Corporate OfficerCeo Oct 7, 2022
Corporate DirectorCeo Oct 7, 2022
W-2 Managing EmployeeCeo Oct 7, 2022
Lupe Tobar Individual Corporate DirectorBoard Chair Jun 30, 2020
Bobby Pierce Individual Corporate DirectorBoard Vice Chair Sep 25, 2018
Janine Wood Individual Corporate DirectorBoard Secretary Sep 24, 2019
Roque Capetillo Individual Corporate DirectorBoard Member Jun 30, 2020

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Midtown Clinic of TylerTyler, TX, CCN 741903 Federally qualified health center Other Jan 10, 1991
Special Health Resources for Texas, IncorporatedTexarkana, TX, CCN 741905 Federally qualified health center Operational/Managerial Control Jan 10, 1991
All for Kids ClinicTexarkana, AR, CCN 041916 Federally qualified health center Other Jan 4, 2016
Special Health Resources for Texas, IncorporatedLongview, TX, CCN 741936 Federally qualified health center Other Nov 16, 2016
Paris ClinicParis, TX, CCN 741977 Federally qualified health center Other Nov 20, 2017
Tyler Care ClinicTyler, TX, CCN 451017 Federally qualified health center Operational/Managerial Control Jan 10, 1991

Owned or controlled facilities with NPI records 6

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

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": "1431648000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674172800000",
    "number": "1750769238",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2709",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "756062709",
            "telephone_number": "903-234-0776",
            "fax_number": "903-234-9769"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "703 E MARSHALL AVE",
            "address_2": "SUITE 310",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "756015500",
            "telephone_number": "603-234-8611",
            "fax_number": "903-758-2283"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPECIAL HEALTH RESOURCES FOR TEXAS, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SPECIAL HEALTH RESOURCES FOR TEXAS, INC.",
        "enumeration_date": "2015-05-15",
        "last_updated": "2023-01-20",
        "certification_date": "2023-01-20",
        "status": "A",
        "authorized_official_last_name": "NESVIG",
        "authorized_official_first_name": "KIM",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "903-234-0776",
        "authorized_official_name_prefix": "Mr."
    },
    "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": "MED PLAZA",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "MED PLAZA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Longview, TX

Sources for this page

Verify at the official NPI Registry.