Provider Demographics
NPI:1932611019
Name:FAMILY CARE PROFESSIONAL LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:FAMILY CARE PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERYL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:859-893-3588
Mailing Address - Street 1:4864 BUD LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514-1416
Mailing Address - Country:US
Mailing Address - Phone:859-358-8533
Mailing Address - Fax:
Practice Address - Street 1:3190 IRVINE RD.
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-4047
Practice Address - Country:US
Practice Address - Phone:859-369-0070
Practice Address - Fax:859-369-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care