Provider Demographics
NPI:1841288602
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:BILLING/CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHANTEL
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:BILLING
Authorized Official - Phone:214-426-3645
Mailing Address - Street 1:2922-B MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215
Mailing Address - Country:US
Mailing Address - Phone:214-426-3645
Mailing Address - Fax:214-426-6813
Practice Address - Street 1:2922-B MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-2471
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:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00920RMedicare ID - Type Unspecified