Provider Demographics
NPI:1134366289
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:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-426-3645
Mailing Address - Street 1:PO BOX 150128
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75315-0128
Mailing Address - Country:US
Mailing Address - Phone:214-426-3645
Mailing Address - Fax:214-426-6813
Practice Address - Street 1:2922 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2: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:214-426-6813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118933336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130713404Medicaid
4576229OtherNCPDP PROVIDER ID
4576229OtherNCPDP PROVIDER ID