Provider Demographics
NPI:1184857195
Name:FAMILY HEALTH CARE CLINIC, INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CARE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-825-7280
Mailing Address - Street 1:PO BOX 24116
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4116
Mailing Address - Country:US
Mailing Address - Phone:601-825-7280
Mailing Address - Fax:601-825-8130
Practice Address - Street 1:1304 13TH AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:601-825-7280
Practice Address - Fax:601-825-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL116356Medicaid