Provider Demographics
NPI:1275756264
Name:PHYSICIANS OF KING'S DAUGHTERS, PA
Entity Type:Organization
Organization Name:PHYSICIANS OF KING'S DAUGHTERS, PA
Other - Org Name:KING'S DAUGHTERS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCCAFFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:254-298-2682
Mailing Address - Street 1:1905 SW H K DODGEN LOOP
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-1814
Mailing Address - Country:US
Mailing Address - Phone:254-298-2682
Mailing Address - Fax:254-778-7197
Practice Address - Street 1:1905 SW H K DODGEN LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1814
Practice Address - Country:US
Practice Address - Phone:254-298-2682
Practice Address - Fax:254-778-7197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181326301Medicaid
TX181326301Medicaid
TX00C399Medicare PIN