Provider Demographics
NPI:1508182197
Name:FAIR MEDICAL CLINIC APMC
Entity Type:Organization
Organization Name:FAIR MEDICAL CLINIC APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-352-6800
Mailing Address - Street 1:615 BIENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5730
Mailing Address - Country:US
Mailing Address - Phone:318-352-6800
Mailing Address - Fax:318-352-6800
Practice Address - Street 1:615 BIENVILLE ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5730
Practice Address - Country:US
Practice Address - Phone:318-352-6800
Practice Address - Fax:318-352-6803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.202650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty