Provider Demographics
NPI:1447367214
Name:CHARLES WILSON V.A. OUTPATIENT CLINIC
Entity type:Organization
Organization Name:CHARLES WILSON V.A. OUTPATIENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-633-2758
Mailing Address - Street 1:1301 WEST FRANK AVENUE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904
Mailing Address - Country:US
Mailing Address - Phone:936-633-2758
Mailing Address - Fax:
Practice Address - Street 1:1301 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3305
Practice Address - Country:US
Practice Address - Phone:936-633-2758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX527049261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center