Provider Demographics
NPI:1912568304
Name:COMMUNITY FAMILY MEDICAL CLINIC, LLC.
Entity Type:Organization
Organization Name:COMMUNITY FAMILY MEDICAL CLINIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MATLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-561-8811
Mailing Address - Street 1:P.O BOX 988
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954
Mailing Address - Country:US
Mailing Address - Phone:918-427-7581
Mailing Address - Fax:918-427-7798
Practice Address - Street 1:1202 FORT STREET
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923
Practice Address - Country:US
Practice Address - Phone:918-427-7581
Practice Address - Fax:918-427-7798
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY FAMILY MEDICAL CLINIC LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty