=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164468039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY FIRST HEALTHCARE OF LUBBOCK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5935 82ND ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-3673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-794-3000
-----------------------------------------------------
Fax | 806-698-0702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5935 82ND ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-3673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-794-3000
-----------------------------------------------------
Fax | 806-698-0702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PHYSICIAN
-----------------------------------------------------
Name | RANDOLPH KYLE ROZEAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 806-794-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H1314
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------