Provider Demographics
NPI:1740334358
Name:FAMILY LIFE CENTER, INC.
Entity type:Organization
Organization Name:FAMILY LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGUNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLECKLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:256-997-9356
Mailing Address - Street 1:300 GAULT AVE S
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-1824
Mailing Address - Country:US
Mailing Address - Phone:256-997-9356
Mailing Address - Fax:256-997-9314
Practice Address - Street 1:300 GAULT AVE S
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-1824
Practice Address - Country:US
Practice Address - Phone:256-997-9356
Practice Address - Fax:256-997-9314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALJ318Medicare ID - Type UnspecifiedGROUP PROVIDER #