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General NPI Number Information
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NPI Number | 1083976989
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Entity Type | Organization
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Legal Business Name | FAMILY PRACTICE OF LOUISA, PLLC
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Dates
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Enumeration Date | 06/15/2012
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Last Update Date | 06/15/2012
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Provider Practice Location Address
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Address Line | 40 MEDICAL HTS
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City | LOUISA
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State | KY
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Zip | 41230-9603
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Country | US
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Telephone | 606-638-0033
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 730
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City | LOUISA
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State | KY
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Zip | 41230-0730
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | JEREMY KLEIN
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Credential | MD
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Telephone | 606-638-0033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 31770
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License Number State | KY
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