| East Texas Family Support Clinic | |
|
1305 Doctors Dr Tyler TX 75701-2263 | |
| (903) 525-9397 | |
| (903) 525-9398 |
| Full Name | East Texas Family Support Clinic |
|---|---|
| Speciality | Clinic/Center |
| Location | 1305 Doctors Dr, Tyler, Texas |
| Authorized Official Name and Position | Jennifer A Blake (OWNER) |
| Authorized Official Contact | 9545572775 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| East Texas Family Support Clinic 1305 Doctors Dr Tyler TX 75701-2263 Ph: (903) 525-9397 | East Texas Family Support Clinic 1305 Doctors Dr Tyler TX 75701-2263 Ph: (903) 525-9397 |
| NPI Number | 1699315499 |
|---|---|
| Provider Enumeration Date | 01/09/2020 |
| Last Update Date | 06/11/2020 |
| Medicare PECOS PAC ID | 6406283811 |
|---|---|
| Medicare Enrollment ID | O20200331000165 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699315499 | NPI | - | NPPES |
| Provider Name | Melissa Anne Neal |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1144239005 PECOS PAC ID: 2365468329 Enrollment ID: I20061205000677 |
| Provider Name | John Paul Fanning |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1952740060 PECOS PAC ID: 3173889235 Enrollment ID: I20171107001500 |
| Provider Name | Lorna Casey Blakney |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1396350039 PECOS PAC ID: 5395155766 Enrollment ID: I20201113002114 |
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