Provider Demographics
NPI:1023366614
Name:TLC FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:TLC FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, C-NP
Authorized Official - Phone:580-584-2643
Mailing Address - Street 1:700 W. JONES
Mailing Address - Street 2:TLC FAMILY CLINIC, LLC
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728
Mailing Address - Country:US
Mailing Address - Phone:580-584-2643
Mailing Address - Fax:
Practice Address - Street 1:700 W. JONES
Practice Address - Street 2:TLC FAMILY CLINIC, LLC
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728
Practice Address - Country:US
Practice Address - Phone:580-584-2643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care