Healthcare Provider Details

I. General information

NPI: 1326355801
Provider Name (Legal Business Name): THE FAMILY CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 IRVINE RD
RICHMOND KY
40475-9031
US

IV. Provider business mailing address

PO BOX 3486
RICHMOND VA
23235-7486
US

V. Phone/Fax

Practice location:
  • Phone: 859-369-0070
  • Fax:
Mailing address:
  • Phone: 804-402-5403
  • Fax: 800-518-9245

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: GEOFFREY PITTMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 804-402-5403