MEDICARE: FAMILY PRACTICE CENTER OF SULPHUR, 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	207Q00000X	Family Medicine Physician

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710188610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PRACTICE CENTER OF SULPHUR, LLC

Provider Business Mailing Address
First Line	:	2509 MAPLEWOOD DR
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70663-6105
Country	:	US
Telephone Number	:	337-625-0341
Fax Number	:	337-625-0347

Provider Business Practice Location Address
First Line	:	2509 MAPLEWOOD DR
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70663-6105
Country	:	US
Telephone Number	:	337-625-0341
Fax Number	:	337-625-0347

Authorized Official
Title or Position	:	CLINIC MANAGER
Name	:	VICKI FITKIN
Credential	:
Telephone Number	:	337-625-0341

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	05/26/2020

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