Provider Demographics
NPI:1558496570
Name:PAINT LICK FAMILY CLINIC INC
Entity type:Organization
Organization Name:PAINT LICK FAMILY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:STROTHER
Authorized Official - Last Name:BELANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-925-2444
Mailing Address - Street 1:11652 HWY 52 RICHMOND ROAD
Mailing Address - Street 2:
Mailing Address - City:PAINT LICK
Mailing Address - State:KY
Mailing Address - Zip Code:40461-0065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11652 HWY 52 RICHMOND ROAD
Practice Address - Street 2:
Practice Address - City:PAINT LICK
Practice Address - State:KY
Practice Address - Zip Code:40461-0065
Practice Address - Country:US
Practice Address - Phone:859-925-2444
Practice Address - Fax:859-925-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65909707Medicaid
E07308Medicare UPIN