Provider Demographics
NPI:1710167713
Name:MATLOCK FAMILY CLINIC, P.A.
Entity Type:Organization
Organization Name:MATLOCK FAMILY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAI
Authorized Official - Middle Name:VQ
Authorized Official - Last Name:HOANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-759-2315
Mailing Address - Street 1:4045 E BELKNAP ST
Mailing Address - Street 2:#12
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76111-6638
Mailing Address - Country:US
Mailing Address - Phone:817-759-2315
Mailing Address - Fax:817-759-2316
Practice Address - Street 1:4045 E BELKNAP ST
Practice Address - Street 2:#12
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76111-6638
Practice Address - Country:US
Practice Address - Phone:817-759-2315
Practice Address - Fax:817-759-2316
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MATLOCK FAMILY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00814XMedicare PIN
TX8D9639Medicare PIN
TX8D9638Medicare PIN