Provider Demographics
NPI:1568614543
Name:FAMILY HEALTH CARE ASSOCIATES OF WILLIAMSBURG
Entity Type:Organization
Organization Name:FAMILY HEALTH CARE ASSOCIATES OF WILLIAMSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:605-546-7777
Mailing Address - Street 1:P.O. BOX 1535
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906
Mailing Address - Country:US
Mailing Address - Phone:606-549-8780
Mailing Address - Fax:606-549-8779
Practice Address - Street 1:965 SOUTH HWY 25
Practice Address - Street 2:STE 52
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769
Practice Address - Country:US
Practice Address - Phone:606-549-8780
Practice Address - Fax:606-549-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3568P261Q00000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100059130Medicaid
KY7100063160Medicaid
KY7100063160Medicaid