Provider Demographics
NPI:1710116066
Name:FAMILY MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-331-9700
Mailing Address - Street 1:160 SAYLORS CV
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-7700
Mailing Address - Country:US
Mailing Address - Phone:256-331-9700
Mailing Address - Fax:256-331-2615
Practice Address - Street 1:1355 GEORGE WALLACE HWY
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35654-3281
Practice Address - Country:US
Practice Address - Phone:256-331-9700
Practice Address - Fax:256-331-2615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-08
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-072201363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty