Provider Demographics
NPI:1275934614
Name:SMITH'S HOMETOWN FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:SMITH'S HOMETOWN FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWANA
Authorized Official - Middle Name:ML
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-599-8905
Mailing Address - Street 1:359 OLD US HIGHWAY 421
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-7538
Mailing Address - Country:US
Mailing Address - Phone:606-599-8905
Mailing Address - Fax:606-599-0354
Practice Address - Street 1:359 OLD US HIGHWAY 421
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7538
Practice Address - Country:US
Practice Address - Phone:606-599-8905
Practice Address - Fax:606-599-0354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006073261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100100870Medicaid
KY11996475OtherCAQH
KY7100100870Medicaid