Provider Demographics
NPI:1972979540
Name:FAMILY PRACTICE OF KENTUCKY LLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF KENTUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP,FNP-BC,RFNA,CNO
Authorized Official - Phone:606-594-1769
Mailing Address - Street 1:204 TOWN BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-1322
Mailing Address - Country:US
Mailing Address - Phone:606-596-7196
Mailing Address - Fax:606-598-1903
Practice Address - Street 1:21 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7012
Practice Address - Country:US
Practice Address - Phone:606-594-1769
Practice Address - Fax:606-596-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101YA0400X, 363L00000X, 363LF0000X
KY900342207Q00000X
261QM1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY193200000XOtherTAXONOMY MULTI SPECIALTY
KY188978OtherMEDICARE PART A
KY900342OtherCOMMONWEALTH OF KY PROVISIONAL LICENSE
KY7100537420Medicaid