Basic Information
| Provider Information | |||||||||
| NPI: | 1558496570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAINT LICK FAMILY CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11652 HWY 52 RICHMOND ROAD | ||||||||
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| City: | PAINT LICK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404610065 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11652 HWY 52 RICHMOND ROAD | ||||||||
| Address2: | |||||||||
| City: | PAINT LICK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404610065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599252444 | ||||||||
| FaxNumber: | 8599252334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BELANGER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | STROTHER | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8599252444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26657 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65909707 | 05 | KY | MEDICAID |