Provider Demographics
NPI:1215510490
Name:FCC MEDICAL CLINICS LLC
Entity type:Organization
Organization Name:FCC MEDICAL CLINICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-888-5925
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-0071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8685
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:573-778-9492
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY COUNSELING CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-04
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty