Provider Demographics
NPI:1710188610
Name:FAMILY PRACTICE CENTER OF SULPHUR, LLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE CENTER OF SULPHUR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:FITKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-625-0341
Mailing Address - Street 1:2509 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6105
Mailing Address - Country:US
Mailing Address - Phone:337-625-0341
Mailing Address - Fax:337-625-0347
Practice Address - Street 1:2509 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-6105
Practice Address - Country:US
Practice Address - Phone:337-625-0341
Practice Address - Fax:337-625-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1684643Medicaid
LA1682969Medicaid
LAG39732Medicare UPIN
LA1682969Medicaid
LA1684643Medicaid