Provider Demographics
NPI:1558402867
Name:FAMILY PRACTICE CARE LLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-545-3386
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:700 CASSIDY AVE
Mailing Address - City:FREDONIA
Mailing Address - State:KY
Mailing Address - Zip Code:42411
Mailing Address - Country:US
Mailing Address - Phone:270-545-3386
Mailing Address - Fax:270-545-3712
Practice Address - Street 1:700 CASSIDY AVE
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:KY
Practice Address - Zip Code:42411
Practice Address - Country:US
Practice Address - Phone:270-545-3386
Practice Address - Fax:270-545-3712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3001776363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78903812Medicaid
KY9335 PTANMedicare PIN