Provider Demographics
NPI:1326391947
Name:POTTERS HOUSE FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:POTTERS HOUSE FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IMMACULATA
Authorized Official - Middle Name:
Authorized Official - Last Name:INYANG
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:214-607-3650
Mailing Address - Street 1:7125 MARVIN D LOVE FWY
Mailing Address - Street 2:STE 207
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3175
Mailing Address - Country:US
Mailing Address - Phone:214-607-3650
Mailing Address - Fax:
Practice Address - Street 1:7125 MARVIN D LOVE FWY
Practice Address - Street 2:STE 207
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3175
Practice Address - Country:US
Practice Address - Phone:214-607-3650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX808591363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty