1629342985 NPI number — THACKER FAMILY MEDICAL LLC

Table of content: (NPI 1629342985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629342985 NPI number — THACKER FAMILY MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THACKER FAMILY MEDICAL LLC
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:
1629342985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1228
Provider Second Line Business Mailing Address:
140 ADAMS LANE, SUITE 600-700
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41502-1228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-509-2000
Provider Business Mailing Address Fax Number:
606-509-2002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 ADAMS LN
Provider Second Line Business Practice Location Address:
SUITE 600-700
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41501-3087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-509-2000
Provider Business Practice Location Address Fax Number:
606-509-2002
Provider Enumeration Date:
03/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
THACKER
Authorized Official First Name:
CHADWARD
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
SOILE MEMBER/OWNER
Authorized Official Telephone Number:
606-509-2000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  38711 , 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)





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