1568614543 NPI number — FAMILY HEALTH CARE ASSOCIATES OF WILLIAMSBURG

Table of content: (NPI 1568614543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568614543 NPI number — FAMILY HEALTH CARE ASSOCIATES OF WILLIAMSBURG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY HEALTH CARE ASSOCIATES OF WILLIAMSBURG
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:
1568614543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARBOURVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-549-8780
Provider Business Mailing Address Fax Number:
606-549-8779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
965 SOUTH HWY 25
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-549-8780
Provider Business Practice Location Address Fax Number:
606-549-8779
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GOOD
Authorized Official First Name:
GINA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CLINIC OWNER
Authorized Official Telephone Number:
605-546-7777

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 3568P , 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: 7100059130 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100063160 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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