Provider Demographics
NPI:1851492557
Name:MARTIN LUTHER KING JR FAMILY CLINIC
Entity Type:Organization
Organization Name:MARTIN LUTHER KING JR FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:214-426-3645
Mailing Address - Street 1:2922 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215-2321
Mailing Address - Country:US
Mailing Address - Phone:214-426-3645
Mailing Address - Fax:214-446-2018
Practice Address - Street 1:2922 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:BUILDING B
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-2321
Practice Address - Country:US
Practice Address - Phone:214-426-3645
Practice Address - Fax:214-446-2018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130713406Medicaid
TX130713412Medicaid
TX183600Medicaid
TXTXB104577OtherMEDICARE PTAN
TX130713404Medicaid
TX130713410Medicaid
183600OtherUNICARE
TX130713409Medicaid
TXQQ04OtherBLUE CROSS BLUE SHIELD
TX130713408Medicaid
TX1949Medicaid
TX130713409Medicaid
TX130713404Medicaid