Provider Demographics
NPI:1689919078
Name:MOUNTAIN FAMILY PRACTICE CLINIC OF MANCHESTER INC
Entity Type:Organization
Organization Name:MOUNTAIN FAMILY PRACTICE CLINIC OF MANCHESTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:B
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:859-358-4222
Mailing Address - Street 1:86 HIGHWAY 638 STE 1
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-7289
Mailing Address - Country:US
Mailing Address - Phone:606-596-0701
Mailing Address - Fax:606-596-0703
Practice Address - Street 1:86 HIGHWAY 638
Practice Address - Street 2:STE 1
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7289
Practice Address - Country:US
Practice Address - Phone:606-596-0701
Practice Address - Fax:606-596-0703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100299490Medicaid
KY7100257320Medicaid
KY7100299490Medicaid