Healthcare Provider Details

I. General information

NPI: 1619258498
Provider Name (Legal Business Name): FYI HEALTHCARE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 N MAIN ST SUITE 101
BEAVER DAM KY
42320-8955
US

IV. Provider business mailing address

1219 N MAIN ST SUITE 101
BEAVER DAM KY
42320-8955
US

V. Phone/Fax

Practice location:
  • Phone: 270-274-0638
  • Fax: 270-274-5600
Mailing address:
  • Phone: 270-274-0638
  • Fax: 270-274-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number13394
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3003830
License Number StateKY

VIII. Authorized Official

Name: SUSAN SMITH RICE
Title or Position: CO-OWNER
Credential: APRN
Phone: 270-274-0638