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General NPI Number Information
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NPI Number | 1124596341
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Entity Type | Organization
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Legal Business Name | BLUEGRASS FAMILY WALK-IN CLINIC LLC
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Dates
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Enumeration Date | 11/06/2018
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Last Update Date | 11/06/2018
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Provider Practice Location Address
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Address Line | 140 ADAMS LN STE 600-700
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City | PIKEVILLE
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State | KY
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Zip | 41501-3087
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Country | US
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Telephone | 606-509-2000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1228
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City | PIKEVILLE
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State | KY
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Zip | 41502-1228
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Country | US
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Telephone | 606-509-2000
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Fax | 606-509-2002
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHADWARD LEE THACKER
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Credential | MD
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Telephone | 606-509-2000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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