Provider Demographics
NPI:1699315499
Name:EAST TEXAS FAMILY SUPPORT CLINIC
Entity type:Organization
Organization Name:EAST TEXAS FAMILY SUPPORT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-557-2775
Mailing Address - Street 1:1305 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2263
Mailing Address - Country:US
Mailing Address - Phone:903-525-9397
Mailing Address - Fax:903-525-9398
Practice Address - Street 1:1305 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2263
Practice Address - Country:US
Practice Address - Phone:903-525-9397
Practice Address - Fax:903-525-9398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty