Provider Demographics
NPI:1629044326
Name:FAMILY DIAGNOSTIC MEDICAL CENTER,LLP
Entity Type:Organization
Organization Name:FAMILY DIAGNOSTIC MEDICAL CENTER,LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBAJAL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:254-580-1550
Mailing Address - Street 1:1323 E FRANKLIN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HILLSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76645-2678
Mailing Address - Country:US
Mailing Address - Phone:254-582-7481
Mailing Address - Fax:254-582-1584
Practice Address - Street 1:1323 E FRANKLIN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:HILLSBORO
Practice Address - State:TX
Practice Address - Zip Code:76645-2678
Practice Address - Country:US
Practice Address - Phone:254-582-7481
Practice Address - Fax:254-582-1584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093773201Medicaid
TX093773204Medicaid
TX093773203Medicaid
TX093773201Medicaid
TX093773203Medicaid