Provider Demographics
NPI:1194775734
Name:FAMILY CARE CENTER MAGNOLIA
Entity type:Organization
Organization Name:FAMILY CARE CENTER MAGNOLIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:D
Authorized Official - Last Name:KINGERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-706-1900
Mailing Address - Street 1:PO BOX 2309
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2309
Mailing Address - Country:US
Mailing Address - Phone:270-706-1131
Mailing Address - Fax:270-706-1167
Practice Address - Street 1:432 MILL RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:KY
Practice Address - Zip Code:42757-7862
Practice Address - Country:US
Practice Address - Phone:270-324-3241
Practice Address - Fax:270-324-3244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935678Medicaid
KYDA0342OtherMEDICARE RAILROAD
KYDA0342OtherMEDICARE RAILROAD