Provider Demographics
NPI:1407128267
Name:MODOC FAMILY MEDICINE
Entity Type:Organization
Organization Name:MODOC FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-994-0451
Mailing Address - Street 1:300 W CENTRAL TEXAS EXPY STE 115
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-1888
Mailing Address - Country:US
Mailing Address - Phone:254-833-8456
Mailing Address - Fax:
Practice Address - Street 1:300 W CENTRAL TEXAS EXPY STE 115
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1888
Practice Address - Country:US
Practice Address - Phone:254-833-8456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty