Provider Demographics
NPI:1679053581
Name:FAMILY CARE CLINIC PLLC
Entity Type:Organization
Organization Name:FAMILY CARE CLINIC PLLC
Other - Org Name:FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:859-893-3588
Mailing Address - Street 1:3190 IRVINE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-9031
Mailing Address - Country:US
Mailing Address - Phone:859-369-0070
Mailing Address - Fax:859-369-0073
Practice Address - Street 1:3190 IRVINE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-9031
Practice Address - Country:US
Practice Address - Phone:859-369-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty