Basic Information
| Provider Information | |||||||||
| NPI: | 1073565685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KELL WEST FAMILY PRACTICE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 KELL BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763101612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406960011 | ||||||||
| FaxNumber: | 9406962248 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 KELL WEST BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763101612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406960011 | ||||||||
| FaxNumber: | 9406962248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOISANT | ||||||||
| AuthorizedOfficialFirstName: | MICHEAL | ||||||||
| AuthorizedOfficialMiddleName: | ALLAN | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9406960011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | CK5579 | 01 | TX | RAILROAD MEDICARE | OTHER | 0078HQ | 01 | TX | BCBS OF TEXAS | OTHER |