Basic Information
| Provider Information | |||||||||
| NPI: | 1215397294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KFC MEDICAL PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650444 | ||||||||
| Address2: | DEPT 121 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
| FaxNumber: | 9724791118 | ||||||||
| Practice Location | |||||||||
| Address1: | 5045 LORIMAR DR | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750935720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724031463 | ||||||||
| FaxNumber: | 9724031465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2016 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | FLANAGAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2148207246 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | J8977 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.