=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700150869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY MEDICINE RURAL HEALTH CLINIC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2012
-----------------------------------------------------
Last Update Date | 03/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 WALKER PLACE BLVD
-----------------------------------------------------
City | COPPERAS COVE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76522-4025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-547-5516
-----------------------------------------------------
Fax | 254-542-0039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 W AVENUE E
-----------------------------------------------------
City | LAMPASAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76550-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-556-3621
-----------------------------------------------------
Fax | 512-556-4080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK S LANE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 512-556-3621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------