Healthcare Provider Details

I. General information

NPI: 1215510490
Provider Name (Legal Business Name): FCC MEDICAL CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 WARRIOR LN
POPLAR BLUFF MO
63901-8685
US

IV. Provider business mailing address

PO BOX 71
KENNETT MO
63857-0071
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-1200
  • Fax: 573-778-9492
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY ELLIS
Title or Position: CCO
Credential:
Phone: 573-888-5925