Provider Demographics
NPI:1720723513
Name:FAITH AND FAMILY MEDICAL PROVIDERS PLLC
Entity Type:Organization
Organization Name:FAITH AND FAMILY MEDICAL PROVIDERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLADDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-310-5206
Mailing Address - Street 1:363 HIGHWAY 371 S
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-8960
Mailing Address - Country:US
Mailing Address - Phone:479-310-5206
Mailing Address - Fax:
Practice Address - Street 1:363 HIGHWAY 371 S
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-8960
Practice Address - Country:US
Practice Address - Phone:573-202-4070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-SurgicalGroup - Multi-Specialty