Provider Demographics
NPI:1912111618
Name:STRATFORD FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:STRATFORD FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, FNP-C
Authorized Official - Phone:806-396-5583
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79084-1107
Mailing Address - Country:US
Mailing Address - Phone:806-396-5583
Mailing Address - Fax:806-366-2713
Practice Address - Street 1:1220 PURNELL
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:TX
Practice Address - Zip Code:79084-1107
Practice Address - Country:US
Practice Address - Phone:806-396-5583
Practice Address - Fax:806-366-2713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
TX578145363LA2100X
TX567349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOA3903Medicare Oscar/Certification