Provider Demographics
NPI:1447201207
Name:MANCHESTER FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:MANCHESTER FAMILY PRACTICE CLINIC
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 1:2734 S HIGHWAY 421
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7515
Practice Address - Country:US
Practice Address - Phone:606-599-0609
Practice Address - Fax:606-599-8419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001072Medicaid
KY35001072Medicaid
KY6866Medicare ID - Type Unspecified