Provider Demographics
NPI:1194794230
Name:MARATHON PRIMARY CARE SERVICES, INC.
Entity type:Organization
Organization Name:MARATHON PRIMARY CARE SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-386-4316
Mailing Address - Street 1:PO BOX 846339
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 SOUTH FIRST
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:TX
Practice Address - Zip Code:79842
Practice Address - Country:US
Practice Address - Phone:432-386-4316
Practice Address - Fax:432-386-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0942160261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX673808Medicare Oscar/Certification