Provider Demographics
NPI:1720687007
Name:HOMETOWN FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:HOMETOWN FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:419-771-1640
Mailing Address - Street 1:1198 WESTWOOD DR STE F
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2478
Mailing Address - Country:US
Mailing Address - Phone:419-771-1640
Mailing Address - Fax:
Practice Address - Street 1:1198 WESTWOOD DR STE F
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2478
Practice Address - Country:US
Practice Address - Phone:419-771-1640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1619955754Medicaid