Healthcare Provider Details

I. General information

NPI: 1104835743
Provider Name (Legal Business Name): PERRY COUNTY FAMILY PRACTICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 AIRPORT RD
NEW LEXINGTON OH
43764-9749
US

IV. Provider business mailing address

1625 AIRPORT RD
NEW LEXINGTON OH
43764-9749
US

V. Phone/Fax

Practice location:
  • Phone: 740-342-5158
  • Fax: 740-342-7393
Mailing address:
  • Phone: 740-342-5158
  • Fax: 740-342-7393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number35-042516
License Number StateOH

VIII. Authorized Official

Name: MRS. THERESA L ULRICH
Title or Position: OWNER/SOCIAL WORKER
Credential: MSW, LISW
Phone: 740-342-5158