1568614543 NPI number — FAMILY HEALTH CARE ASSOCIATES OF WILLIAMSBURG

Table of Contents

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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