Provider Demographics
NPI:1295066280
Name:CEDAR RIDGE FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:CEDAR RIDGE FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, CFNP
Authorized Official - Phone:972-298-6174
Mailing Address - Street 1:222 S CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4529
Mailing Address - Country:US
Mailing Address - Phone:972-298-6174
Mailing Address - Fax:972-709-1570
Practice Address - Street 1:222 S CEDAR RIDGE DR
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4529
Practice Address - Country:US
Practice Address - Phone:972-298-6174
Practice Address - Fax:972-709-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX666524363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty