Provider Demographics
NPI:1437210457
Name:FAMILY CARE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:FAMILY CARE MEDICAL CLINIC, LLC
Other - Org Name:FAMILY CARE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLANCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-840-4175
Mailing Address - Street 1:109 PARK GATE EXT
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3038
Mailing Address - Country:US
Mailing Address - Phone:662-840-4175
Mailing Address - Fax:662-840-8279
Practice Address - Street 1:109 PARK GATE EXT
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3038
Practice Address - Country:US
Practice Address - Phone:662-840-4175
Practice Address - Fax:662-840-8279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR729086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124764Medicaid
MSP4511Medicare UPIN