Healthcare Provider Details

I. General information

NPI: 1154579050
Provider Name (Legal Business Name): FAMILY CARE CENTER CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 RED MILE PL
LEXINGTON KY
40504-1172
US

IV. Provider business mailing address

1135 RED MILE PL
LEXINGTON KY
40504-1172
US

V. Phone/Fax

Practice location:
  • Phone: 859-288-4097
  • Fax:
Mailing address:
  • Phone: 859-288-4097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number3109
License Number StateKY

VIII. Authorized Official

Name: TOM YOUNG
Title or Position: MEDICAL CENTER DIRECTOR
Credential: M.D
Phone: 859-288-4057