Provider Demographics
NPI:1083976989
Name:FAMILY PRACTICE OF LOUISA, PLLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF LOUISA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-638-0033
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-0730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 MEDICAL HTS
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-9603
Practice Address - Country:US
Practice Address - Phone:606-638-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31770261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care