Healthcare Provider Details

I. General information

NPI: 1134898364
Provider Name (Legal Business Name): THACKER FAMILY MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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