Provider Demographics
NPI:1346474707
Name:FAMILY HEALTHCARE OF WYTHEVILLE, PC
Entity Type:Organization
Organization Name:FAMILY HEALTHCARE OF WYTHEVILLE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:SHAE
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-227-0200
Mailing Address - Street 1:1040 HOLSTON RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-4107
Mailing Address - Country:US
Mailing Address - Phone:276-227-0200
Mailing Address - Fax:276-227-0202
Practice Address - Street 1:1040 HOLSTON RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-4107
Practice Address - Country:US
Practice Address - Phone:276-227-0200
Practice Address - Fax:276-227-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346474707Medicaid
VA1346474707Medicaid