Healthcare Provider Details

I. General information

NPI: 1841621679
Provider Name (Legal Business Name): SOUTHWEST FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E 11TH ST
LIBERAL KS
67901-2784
US

IV. Provider business mailing address

102 E 11TH ST
LIBERAL KS
67901-2784
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-2565
  • Fax:
Mailing address:
  • Phone: 620-624-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5376034072
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5345642
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18124
License Number StateKS

VIII. Authorized Official

Name: JUVY JABEL
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 620-624-2565