Provider Demographics
NPI:1255881033
Name:LIVING FREE RECOVERY, PLLC
Entity type:Organization
Organization Name:LIVING FREE RECOVERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-886-0224
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-5810
Mailing Address - Country:US
Mailing Address - Phone:606-886-0224
Mailing Address - Fax:606-886-9908
Practice Address - Street 1:400 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1080
Practice Address - Country:US
Practice Address - Phone:606-886-0224
Practice Address - Fax:606-886-9908
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMETOWN FAMILY CARE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02805207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64061328Medicaid
KY64061328Medicaid