Provider Demographics
NPI:1023285624
Name:FAMILY CARE HEALTH CENTERS
Entity type:Organization
Organization Name:FAMILY CARE HEALTH CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-481-1615
Mailing Address - Street 1:4352 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2138
Mailing Address - Country:US
Mailing Address - Phone:314-481-1615
Mailing Address - Fax:314-353-1310
Practice Address - Street 1:4352 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2138
Practice Address - Country:US
Practice Address - Phone:314-481-1616
Practice Address - Fax:314-353-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606023604Medicaid
MO500858417Medicaid
MO500968417Medicaid
MO500968425Medicaid
MO606023604Medicaid