Provider Demographics
NPI:1326152109
Name:FAMILY PRACTICE CLINIC OF BOONEVILLE, INC.
Entity Type:Organization
Organization Name:FAMILY PRACTICE CLINIC OF BOONEVILLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-593-6023
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:200 MULBERRY STREET, SUITE A
Mailing Address - City:BOONEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41314-0737
Mailing Address - Country:US
Mailing Address - Phone:606-593-6023
Mailing Address - Fax:606-593-6087
Practice Address - Street 1:200 MULBERRY ST
Practice Address - Street 2:SUITE A
Practice Address - City:BOONEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41314-7505
Practice Address - Country:US
Practice Address - Phone:606-593-6023
Practice Address - Fax:606-593-6087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100159610Medicaid
KY183898Medicare Oscar/Certification
KY7443350001Medicare NSC
KY0673201Medicare PIN