Basic Information
| Provider Information | |||||||||
| NPI: | 1023285624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY CARE HEALTH CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4352 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144811615 | ||||||||
| FaxNumber: | 3143531310 | ||||||||
| Practice Location | |||||||||
| Address1: | 4352 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144811616 | ||||||||
| FaxNumber: | 3143531310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MADDOX | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3144811615 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 606023604 | 05 | MO | MEDICAID | 500858417 | 05 | MO | MEDICAID | 500968417 | 05 | MO | MEDICAID | 500968425 | 05 | MO | MEDICAID |