Provider Demographics
NPI:1225782824
Name:MARTIN LUTHER KING JR FAMILY CLINIC
Entity Type:Organization
Organization Name:MARTIN LUTHER KING JR FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JOLIE
Authorized Official - Middle Name:LYON
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-426-3645
Mailing Address - Street 1:PO BOX 150128
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75315-0128
Mailing Address - Country:US
Mailing Address - Phone:214-426-3645
Mailing Address - Fax:214-446-2018
Practice Address - Street 1:10327 RYLIE RD OFC 4
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-8240
Practice Address - Country:US
Practice Address - Phone:214-426-3645
Practice Address - Fax:214-446-2018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)