Provider Demographics
NPI:1033112362
Name:CRAB ORCHARD FAMILY PRACTICE CLINIC, INC.
Entity Type:Organization
Organization Name:CRAB ORCHARD FAMILY PRACTICE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:606-528-0283
Mailing Address - Street 1:PO BOX 1125
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1125
Mailing Address - Country:US
Mailing Address - Phone:606-528-0283
Mailing Address - Fax:606-528-8422
Practice Address - Street 1:207 MAIN ST
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:KY
Practice Address - Zip Code:40419-9697
Practice Address - Country:US
Practice Address - Phone:606-355-7300
Practice Address - Fax:606-355-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3630P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35-001353Medicaid
KY35-001353Medicaid
KY18-3908Medicare ID - Type UnspecifiedRHC