=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841288602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARTIN LUTHER KING JR FAMILY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2922-B MARTIN LUTHER KING JR BLVD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75215-2471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-426-3645
-----------------------------------------------------
Fax | 214-426-6813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2922-B MARTIN LUTHER KING JR BLVD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-426-3645
-----------------------------------------------------
Fax | 214-426-6813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING/CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | MS. CHANTEL DENISE MILLER
-----------------------------------------------------
Credential | BILLING
-----------------------------------------------------
Telephone | 214-426-3645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------