Provider Demographics
NPI:1285777607
Name:FAMILY CARE CLINIC, LLC
Entity type:Organization
Organization Name:FAMILY CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:OURADA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN-C
Authorized Official - Phone:307-745-0085
Mailing Address - Street 1:204 MCCOLLUM ST STE 104
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5151
Mailing Address - Country:US
Mailing Address - Phone:307-745-0085
Mailing Address - Fax:307-745-0084
Practice Address - Street 1:204 MCCOLLUM ST STE 104
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5151
Practice Address - Country:US
Practice Address - Phone:307-745-0085
Practice Address - Fax:307-745-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2023-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118524100Medicaid
WY53D1012895OtherCLIA
WY53D1012895OtherCLIA