MEDICARE: FAMILY CARE CLINIC, 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	261QP2300X	Primary Care Clinic/Center

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
2	53D1012895	OTHER	WY	CLIA

General Provider Information

NPI Number	:	1285777607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY CARE CLINIC, LLC

Provider Business Mailing Address
First Line	:	204 MCCOLLUM ST STE 104
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5151
Country	:	US
Telephone Number	:	307-745-0085
Fax Number	:	307-745-0084

Provider Business Practice Location Address
First Line	:	204 MCCOLLUM ST STE 104
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5151
Country	:	US
Telephone Number	:	307-745-0085
Fax Number	:	307-745-0084

Authorized Official
Title or Position	:	OWNER
Name	:	TERI JEAN OURADA
Credential	:	DNP, APRN-C
Telephone Number	:	307-745-0085

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	04/30/2023

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Directions to “FAMILY CARE CLINIC, LLC ” Practice Location

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