Provider Demographics
NPI:1467563114
Name:C&J FAMILY HEALTH CARE CLINIC, LLC
Entity Type:Organization
Organization Name:C&J FAMILY HEALTH CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP
Authorized Official - Phone:219-345-5151
Mailing Address - Street 1:11920 W STATE ROAD 10
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-9755
Mailing Address - Country:US
Mailing Address - Phone:219-345-5151
Mailing Address - Fax:219-345-5252
Practice Address - Street 1:11920 W STATE ROAD 10
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9755
Practice Address - Country:US
Practice Address - Phone:219-345-5151
Practice Address - Fax:219-345-5252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000776A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN235510Medicare ID - Type Unspecified