Provider Demographics
NPI:1215135801
Name:JARBOE FAMILY PRACTICE, PSC
Entity type:Organization
Organization Name:JARBOE FAMILY PRACTICE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:JARBOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-230-8200
Mailing Address - Street 1:912 WALLACE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-2405
Mailing Address - Country:US
Mailing Address - Phone:270-230-8200
Mailing Address - Fax:270-230-0882
Practice Address - Street 1:912 WALLACE AVE STE 103
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2405
Practice Address - Country:US
Practice Address - Phone:270-230-8200
Practice Address - Fax:270-230-0882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65937013Medicaid
KY65937013Medicaid