Healthcare Provider Details

I. General information

NPI: 1316143845
Provider Name (Legal Business Name): VINE GROVE FAMILY MEDICINE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W MAIN ST
VINE GROVE KY
40175-1302
US

IV. Provider business mailing address

101 W MAIN ST
VINE GROVE KY
40175-1302
US

V. Phone/Fax

Practice location:
  • Phone: 270-877-6672
  • Fax:
Mailing address:
  • Phone: 270-877-6672
  • Fax:

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: TIMOTHY D. LAW SR.
Title or Position: PHYSICIAN AND OWNER
Credential:
Phone: 270-877-6672