Provider Demographics
NPI:1114188943
Name:CENTRAL PARK CLINIC COORPORATION
Entity Type:Organization
Organization Name:CENTRAL PARK CLINIC COORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP-C
Authorized Official - Phone:254-732-4139
Mailing Address - Street 1:8020 CENTRAL PARK DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6652
Mailing Address - Country:US
Mailing Address - Phone:254-732-4139
Mailing Address - Fax:254-732-4209
Practice Address - Street 1:8020 CENTRAL PARK DR
Practice Address - Street 2:SUITE 3
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6652
Practice Address - Country:US
Practice Address - Phone:254-732-4139
Practice Address - Fax:254-732-4209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty