Basic Information
| Provider Information | |||||||||
| NPI: | 1457781486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY HEALTH CARE CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24116 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392254116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018257280 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 SUPERIOR AVE | ||||||||
| Address2: | |||||||||
| City: | BOGALUSA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005087481 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2013 | ||||||||
| LastUpdateDate: | 07/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | CLAYTON | ||||||||
| AuthorizedOfficialFirstName: | KARINA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6018257280 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 02359533 | 05 | LA | MEDICAID |