Healthcare Provider Details

I. General information

NPI: 1407950538
Provider Name (Legal Business Name): FAMILY PRACTICE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CASSIDY AVE
FREDONIA KY
42411
US

IV. Provider business mailing address

PO BOX 195 700 CASSIDY AVE
FREDONIA KY
42411
US

V. Phone/Fax

Practice location:
  • Phone: 270-545-3386
  • Fax: 270-545-3712
Mailing address:
  • Phone: 270-545-3386
  • Fax: 270-545-3712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT R GRAHAM
Title or Position: OWNER
Credential: MD
Phone: 270-545-3386