MEDICARE: PRIMARY CARE @ HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	363L00000X	Nurse Practitioner
2	363LF0000X	Family Nurse Practitioner
3	207Q00000X	Family Medicine Physician	KY

General Provider Information

NPI Number	:	1003137605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE @ HOME, LLC

Provider Business Mailing Address
First Line	:	1105 JULIANNA CT
Second Line	:	SUITE 1
City	:	ELIZABETHTOWN
State	:	KY
Zip	:	42701-7937
Country	:	US
Telephone Number	:	270-763-0030
Fax Number	:	270-763-0050

Provider Business Practice Location Address
First Line	:	1105 JULIANNA CT
Second Line	:	SUITE 1
City	:	ELIZABETHTOWN
State	:	KY
Zip	:	42701-7937
Country	:	US
Telephone Number	:	270-763-0030
Fax Number	:	270-763-0050

Authorized Official
Title or Position	:	CEO
Name	:	DAVID C OWEN
Credential	:
Telephone Number	:	502-254-1111

Provider Enumeration Date	:	06/17/2010
Last Update Date	:	12/03/2010

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