Healthcare Provider Details

I. General information

NPI: 1235697350
Provider Name (Legal Business Name): LAKE KIOWA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KIOWA DR W APT 103
GAINESVILLE TX
76240-9507
US

IV. Provider business mailing address

PO BOX 1358
GAINESVILLE TX
76241-1358
US

V. Phone/Fax

Practice location:
  • Phone: 940-612-5562
  • Fax: 940-665-6201
Mailing address:
  • Phone: 940-612-5562
  • Fax: 940-665-6201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HOLLY OLIVEIRA
Title or Position: OWNER
Credential: FNP
Phone: 940-612-5562