Provider Demographics
NPI:1023527678
Name:HAZARD FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:HAZARD FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:HELTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC, APRN
Authorized Official - Phone:606-233-8140
Mailing Address - Street 1:625 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1511
Mailing Address - Country:US
Mailing Address - Phone:606-435-0001
Mailing Address - Fax:606-435-0058
Practice Address - Street 1:625 MEMORIAL DR STE 1
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1380
Practice Address - Country:US
Practice Address - Phone:606-435-0001
Practice Address - Fax:606-435-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007238261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100200180Medicaid
MH2774873OtherDEA RESGISTRATION