Healthcare Provider Details

I. General information

NPI: 1124596341
Provider Name (Legal Business Name): BLUEGRASS FAMILY WALK-IN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 ADAMS LN STE 600-700
PIKEVILLE KY
41501-3087
US

IV. Provider business mailing address

PO BOX 1228
PIKEVILLE KY
41502-1228
US

V. Phone/Fax

Practice location:
  • Phone: 606-509-2000
  • Fax:
Mailing address:
  • Phone: 606-509-2000
  • Fax: 606-509-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHADWARD LEE THACKER
Title or Position: OWNER
Credential: MD
Phone: 606-509-2000