Healthcare Provider Details

I. General information

NPI: 1194775734
Provider Name (Legal Business Name): FAMILY CARE CENTER MAGNOLIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 MILL RD
MAGNOLIA KY
42757-7862
US

IV. Provider business mailing address

PO BOX 2309
ELIZABETHTOWN KY
42702-2309
US

V. Phone/Fax

Practice location:
  • Phone: 270-324-3241
  • Fax: 270-324-3244
Mailing address:
  • Phone: 270-706-1131
  • Fax: 270-706-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF D KINGERY
Title or Position: DIRECTOR
Credential:
Phone: 270-706-1900