Provider Demographics
NPI:1760675698
Name:FAMILY MEDICINE CLINIC
Entity Type:Organization
Organization Name:FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:C DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NEECE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-738-1164
Mailing Address - Street 1:100 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-1910
Mailing Address - Country:US
Mailing Address - Phone:719-738-1164
Mailing Address - Fax:719-738-3399
Practice Address - Street 1:100 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-1910
Practice Address - Country:US
Practice Address - Phone:719-738-1164
Practice Address - Fax:719-738-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27053208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC444298OtherMEDICARE GROUP NUMBER