MEDICARE: FAMILY CARE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174279301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY CARE CENTER LLC

Provider Business Mailing Address
First Line	:	4730 MORRIS ST
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39563-2838
Country	:	US
Telephone Number	:	228-285-0361
Fax Number	:

Provider Business Practice Location Address
First Line	:	4730 MORRIS ST
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39563-2838
Country	:	US
Telephone Number	:	228-285-0361
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KENDRA S GARDNER
Credential	:	NP
Telephone Number	:	760-443-4616

Provider Enumeration Date	:	02/25/2022
Last Update Date	:	05/23/2022

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Directions to “FAMILY CARE CENTER LLC ” Practice Location

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