Basic Information
| Provider Information | |||||||||
| NPI: | 1003195165 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICINE RURAL HEALTH CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 N WALDRIP ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRAND SALINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751401024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039627551 | ||||||||
| FaxNumber: | 9039627122 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 N WALDRIP ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRAND SALINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751401024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039627551 | ||||||||
| FaxNumber: | 9039627122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2011 | ||||||||
| LastUpdateDate: | 08/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | INGRIM | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9039627551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | G7239 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.