Basic Information
| Provider Information | |||||||||
| NPI: | 1063081263 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FCC MEDICAL CLINICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71 | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638570071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735592365 | ||||||||
| FaxNumber: | 5735592357 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 STATE ROUTE VV | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638573834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735592365 | ||||||||
| FaxNumber: | 5735592357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2021 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CCO | ||||||||
| AuthorizedOfficialTelephone: | 5738885925 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY COUNSELING CENTER, INC | ||||||||
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| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.