Provider Demographics
NPI:1780782672
Name:BRECKENRIDGE FAMILY CLINIC PA
Entity type:Organization
Organization Name:BRECKENRIDGE FAMILY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ELMO
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-559-3363
Mailing Address - Street 1:103 SOUTH HARTFORD STREET
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424
Mailing Address - Country:US
Mailing Address - Phone:254-559-3363
Mailing Address - Fax:254-559-1252
Practice Address - Street 1:103 SOUTH HARTFORD STREET
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424
Practice Address - Country:US
Practice Address - Phone:254-559-3363
Practice Address - Fax:254-559-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82J127OtherBLUE CROSS BLUE SHIELD
TX00D95VMedicare ID - Type Unspecified
C20662Medicare UPIN