Provider Demographics
NPI:1558482091
Name:FAMILY LIFE MEDICAL AND PROSTHETICS, LLC
Entity type:Organization
Organization Name:FAMILY LIFE MEDICAL AND PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:270-217-0798
Mailing Address - Street 1:120 CAVE THOMAS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-5808
Mailing Address - Country:US
Mailing Address - Phone:270-217-0798
Mailing Address - Fax:
Practice Address - Street 1:120 CAVE THOMAS DR
Practice Address - Street 2:SUITE B
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-5808
Practice Address - Country:US
Practice Address - Phone:270-217-0798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY105540332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90009424Medicaid
KY90009424Medicaid