Healthcare Provider Details

I. General information

NPI: 1447201207
Provider Name (Legal Business Name): MANCHESTER FAMILY PRACTICE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2734 S HIGHWAY 421
MANCHESTER KY
40962-7515
US

IV. Provider business mailing address

PO BOX 1125
CORBIN KY
40702-1125
US

V. Phone/Fax

Practice location:
  • Phone: 606-599-0609
  • Fax: 606-599-8419
Mailing address:
  • Phone: 606-528-0283
  • Fax: 606-528-8422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number900112
License Number StateKY

VIII. Authorized Official

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