Healthcare Provider Details

I. General information

NPI: 1558402867
Provider Name (Legal Business Name): FAMILY PRACTICE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 06/26/2014
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 Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3001776
License Number StateKY

VIII. Authorized Official

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