Healthcare Provider Details

I. General information

NPI: 1548596927
Provider Name (Legal Business Name): FREDERICKSBURG FAMILY HEALTH CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 SCHULT RIDGE RD
FREDERICKSBURG IA
50630-9582
US

IV. Provider business mailing address

115 SCHULT RIDGE RD
FREDERICKSBURG IA
50630-9582
US

V. Phone/Fax

Practice location:
  • Phone: 563-237-5316
  • Fax:
Mailing address:
  • Phone: 563-237-5316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number3824
License Number StateIA

VIII. Authorized Official

Name: DR. LUCAS BRINKMAN
Title or Position: OWNER
Credential: D.O.
Phone: 563-237-5316