Provider Demographics
NPI:1073565685
Name:KELL WEST FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:KELL WEST FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:MOISANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:940-696-0011
Mailing Address - Street 1:5500 KELL BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1612
Mailing Address - Country:US
Mailing Address - Phone:940-696-0011
Mailing Address - Fax:940-696-2248
Practice Address - Street 1:5500 KELL WEST BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-1612
Practice Address - Country:US
Practice Address - Phone:940-696-0011
Practice Address - Fax:940-696-2248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCK5579OtherRAILROAD MEDICARE
TX0078HQOtherBCBS OF TEXAS
TXCK5579OtherRAILROAD MEDICARE