Healthcare Provider Details

I. General information

NPI: 1689919078
Provider Name (Legal Business Name): MOUNTAIN FAMILY PRACTICE CLINIC OF MANCHESTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 MANCHESTER SQ SHOPPING CENTER
MANCHESTER KY
40962-7289
US

IV. Provider business mailing address

PO BOX 267
RICHMOND KY
40476-0267
US

V. Phone/Fax

Practice location:
  • Phone: 606-596-0701
  • Fax: 606-596-0703
Mailing address:
  • Phone: 606-596-0701
  • Fax: 606-596-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KIM B COX
Title or Position: OWNER/OPERATOR
Credential: ARNP
Phone: 859-358-4222