1295738524 NPI number — WILLIAMSBURG FAMILY PRACTICE CLINIC, INC.

Table of content: (NPI 1295738524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295738524 NPI number — WILLIAMSBURG FAMILY PRACTICE CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAMSBURG FAMILY PRACTICE CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295738524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORBIN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40702-1125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-528-0283
Provider Business Mailing Address Fax Number:
606-528-8422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
965 S HIGHWAY 25 W
Provider Second Line Business Practice Location Address:
STE 52
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40769-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-549-2588
Provider Business Practice Location Address Fax Number:
606-549-1945
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-528-0283

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  4464P , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 35001098 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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