Healthcare Provider Details

I. General information

NPI: 1942543335
Provider Name (Legal Business Name): CLINE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 HURST ST
CENTER TX
75935-3414
US

IV. Provider business mailing address

4604 NE STALLINGS DR
NACOGDOCHES TX
75965-1608
US

V. Phone/Fax

Practice location:
  • Phone: 936-559-8770
  • Fax: 936-559-8773
Mailing address:
  • Phone: 936-559-8770
  • Fax: 936-559-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberJ8492
License Number StateTX

VIII. Authorized Official

Name: KIM FREEMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 936-559-8770