Provider Demographics
NPI:1942803341
Name:NACOGDOCHES FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:NACOGDOCHES FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YORDANIS
Authorized Official - Middle Name:RAFAEL
Authorized Official - Last Name:FONSECA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C
Authorized Official - Phone:512-909-7332
Mailing Address - Street 1:12521 NACOGDOCHES RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-2117
Mailing Address - Country:US
Mailing Address - Phone:210-634-7814
Mailing Address - Fax:210-634-7815
Practice Address - Street 1:12521 NACOGDOCHES RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-2117
Practice Address - Country:US
Practice Address - Phone:210-634-7814
Practice Address - Fax:210-634-7815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty