Basic Information
Provider Information | |||||||||
NPI: | 1003049016 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY HEALTH CARE CLINIC, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 24116 | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392254116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018257280 | ||||||||
FaxNumber: | 6018258130 | ||||||||
Practice Location | |||||||||
Address1: | 102 PHYSICIANS DR | ||||||||
Address2: | SUITE B | ||||||||
City: | MUSCLE SHOALS | ||||||||
State: | AL | ||||||||
PostalCode: | 35661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018257280 | ||||||||
FaxNumber: | 6018258130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2009 | ||||||||
LastUpdateDate: | 04/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLAYTON | ||||||||
AuthorizedOfficialFirstName: | KARINA | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6018257280 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | AL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 117988 | 05 | AL |   | MEDICAID |