Provider Demographics
NPI:1104099308
Name:FEMCLINIC PLLC
Entity type:Organization
Organization Name:FEMCLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGHDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-488-7878
Mailing Address - Street 1:7155 COLLEYVILLE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-8003
Mailing Address - Country:US
Mailing Address - Phone:817-488-7878
Mailing Address - Fax:817-488-7877
Practice Address - Street 1:7155 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-8003
Practice Address - Country:US
Practice Address - Phone:817-488-7878
Practice Address - Fax:817-488-7877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4208261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0015RQOtherBCBS OF TEXAS
TX0015RQOtherBCBS OF TEXAS