=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861405599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY HEALTH MEDICAL PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 11/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 S HIGHWAY 13
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64067-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-259-2240
-----------------------------------------------------
Fax | 660-259-2250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 S HIGHWAY 13
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64067-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-259-2240
-----------------------------------------------------
Fax | 660-259-2250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VICKI L FOLSOM
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 660-259-2240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------