Basic Information
| Provider Information | |||||||||
| NPI: | 1508840497 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3537 S I-35 E | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762106800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403812313 | ||||||||
| FaxNumber: | 9403815249 | ||||||||
| Practice Location | |||||||||
| Address1: | 3537 S I-35 E | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762106800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403812313 | ||||||||
| FaxNumber: | 9403815249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2005 | ||||||||
| LastUpdateDate: | 06/24/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAPAN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | PATRICE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9403812313 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN,CNS-BC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 119620604 | 05 | TX | MEDICAID |