MEDICARE: CROCKETT CLINIC LLP

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1285626911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROCKETT CLINIC LLP

Provider Business Mailing Address
First Line	:	PO BOX 1189
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1189
Country	:	US
Telephone Number	:	936-544-2157
Fax Number	:	936-544-5572

Provider Business Practice Location Address
First Line	:	1122 E LOOP 304
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1810
Country	:	US
Telephone Number	:	936-544-2157
Fax Number	:	936-544-5572

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. KATHY L RAINS
Credential	:
Telephone Number	:	936-544-2157

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	06/18/2008

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Directions to “CROCKETT CLINIC LLP ” Practice Location

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