Healthcare Provider Details

I. General information

NPI: 1346242641
Provider Name (Legal Business Name): KNOX COUNTY FAMILY PRACTICE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CUMBERLAND GAP PLZ STE 1
GRAY KY
40734-4536
US

IV. Provider business mailing address

PO BOX 1125
CORBIN KY
40702-1125
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-2850
  • Fax: 606-528-1131
Mailing address:
  • Phone: 606-528-0283
  • Fax: 606-528-8422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2774P
License Number StateKY

VIII. Authorized Official

Name: ROBERT A. CARTER JR.
Title or Position: PRESIDENT
Credential:
Phone: 606-528-0283