Provider Demographics
NPI:1487080800
Name:COFFEYVILLE FAMILY PRACTICE CLINIC, P.A.
Entity type:Organization
Organization Name:COFFEYVILLE FAMILY PRACTICE CLINIC, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-251-1100
Mailing Address - Street 1:209 W 7TH ST
Mailing Address - Street 2:C/O COFFEYVILLE FAMILY PRACTICE CLINIC, P.A.
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-4954
Mailing Address - Country:US
Mailing Address - Phone:620-251-1100
Mailing Address - Fax:620-251-7466
Practice Address - Street 1:1318 W 11TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3608
Practice Address - Country:US
Practice Address - Phone:620-688-6373
Practice Address - Fax:620-688-6313
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COFFEYVILLE FAMILY PRACTICE CLINIC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098700AMedicaid
KS100098700AMedicaid