NPIMap

Organization Active NPI

East Texas Border Health Clinic

Doing business as Genesis PrimeCare

  • Federally Qualified Health Center (FQHC)
  • Marshall, TX
National Provider Identifier
1922532555
Registry record updated Jun 13, 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
620 S Grove St Ste 105
Marshall, TX 75670-5295
Phone
(903) 935-9441
NPI assigned
Apr 20, 2017
Last updated
Jun 13, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Pediatrics Physician 208000000X NU

Addresses

Primary practice location

620 S Grove St Ste 105
Marshall, TX 75670-5295

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
373432901MedicaidTX

Other names 1

  • Genesis PrimeCare Doing business as

Medicare participation

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

Enrollment records 2

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
O20170630001102 TX Part A Provider - Federally Qualified Health Center (FQHC) 8820038565 Practice locations: Marshall, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1922532555. Details of each certification follow.

Federally qualified health center certification: CCN 741961

Legal name
EAST TEXAS BORDER HEALTH CLINIC
Doing business as
GENESIS PRIMECARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 29, 2017
Last certification
Jun 29, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 15, 2004 in TX
Enrollment address
620 S Grove St, Ste 105
Genesis Primecare
Marshall, TX 75670-5295

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 17

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

View all 17

National Provider Directory

National Provider Directory

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 OfficerCeo May 1, 2014
Alana Higgins Individual Corporate DirectorBoard Member Jul 29, 2021
Marva Simpson Individual Corporate DirectorBoard Member Feb 22, 2018
Michael G Boles Individual Corporate DirectorBoard Member Dec 20, 2012
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.

Practitioners & affiliated clinicians

Practitioners 2

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": "1492646400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718236800000",
    "number": "1922532555",
    "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": "620 S GROVE ST STE 105",
            "city": "MARSHALL",
            "state": "TX",
            "postal_code": "756705295",
            "telephone_number": "903-935-9441"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TEXAS BORDER HEALTH CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-04-20",
        "last_updated": "2024-06-13",
        "certification_date": "2024-06-13",
        "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": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "373432901",
            "state": "TX"
        }
    ],
    "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 Marshall, TX

Sources for this page

Verify at the official NPI Registry.