Healthcare Provider Details

I. General information

NPI: 1326152109
Provider Name (Legal Business Name): FAMILY PRACTICE CLINIC OF BOONEVILLE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MULBERRY ST SUITE A
BOONEVILLE KY
41314-7505
US

IV. Provider business mailing address

PO BOX 737 200 MULBERRY STREET, SUITE A
BOONEVILLE KY
41314-0737
US

V. Phone/Fax

Practice location:
  • Phone: 606-593-6023
  • Fax: 606-593-6087
Mailing address:
  • Phone: 606-593-6023
  • Fax: 606-593-6087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM COX
Title or Position: OWNER OPERATOR
Credential: APRN
Phone: 606-593-6023