| Organization Name: | CANYON LAKE MEDICAL CLINIC |
| NPI Number: | 1124121009 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JEFF P MADISON (OWNER) |
| Mailing Address: | 1356 Fm 2673 Canyon Lake |
| State: | TX US |
| Postal Code: | 781334510 |
| Phone Number: | 8309643019 |
| Fax Number: | 8302265002 |
| NPI Enumeration Date: | 09/06/2006 |
| NPI Last Update Date: | 08/25/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR1300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rural Health |
| Taxonomy Definition: | |