Healthcare Provider Details

I. General information

NPI: 1215397294
Provider Name (Legal Business Name): KFC MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5045 LORIMAR DR SUITE 290
PLANO TX
75093-5720
US

IV. Provider business mailing address

PO BOX 650444 DEPT 121
DALLAS TX
75265-0444
US

V. Phone/Fax

Practice location:
  • Phone: 972-403-1463
  • Fax: 972-403-1465
Mailing address:
  • Phone: 972-479-1115
  • Fax: 972-479-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberJ8977
License Number StateTX

VIII. Authorized Official

Name: BRIAN FLANAGAN
Title or Position: MANAGER
Credential: MD
Phone: 214-820-7246