Provider Demographics
NPI:1174279301
Name:FAMILY CARE CENTER LLC
Entity Type:Organization
Organization Name:FAMILY CARE CENTER LLC
Other - Org Name:FAMILY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:760-443-4616
Mailing Address - Street 1:4730 MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-2838
Mailing Address - Country:US
Mailing Address - Phone:228-285-0361
Mailing Address - Fax:
Practice Address - Street 1:4730 MORRIS ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-2838
Practice Address - Country:US
Practice Address - Phone:228-285-0361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3227521Medicaid