Provider Demographics
NPI:1154547347
Name:FAITH FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:FAITH FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-743-1422
Mailing Address - Street 1:801 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-1021
Mailing Address - Country:US
Mailing Address - Phone:606-743-1422
Mailing Address - Fax:606-743-3044
Practice Address - Street 1:801 N. MAIN STR.
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1021
Practice Address - Country:US
Practice Address - Phone:606-743-1422
Practice Address - Fax:606-743-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65905721Medicaid
KY65905721Medicaid
KY0647301Medicare PIN