Organization
CANYON LAKE MEDICAL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEFF P MADISON (OWNER)
(512) 446-4500
Entity
Organization
Contact information
Practice address
1356 FM 2673, CANYON LAKE, TX 78133-4510
(830) 964-3019
(830) 226-5002
Mailing address
1356 FM 2673, CANYON LAKE, TX 78133-4510
(830) 964-3019
(830) 226-5002
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0022HN
BLUE CROSS/BLUE SHIELD
TX
05
—
164301701
—
TX
05
—
164301702
—
TX
05
—
164301703
—
TX
Enumeration date
09/06/2006
Last updated
08/25/2011
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