Provider Demographics
NPI:1295738524
Name:WILLIAMSBURG FAMILY PRACTICE CLINIC, INC.
Entity type:Organization
Organization Name:WILLIAMSBURG FAMILY PRACTICE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:606-528-0283
Mailing Address - Street 1:PO BOX 1125
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1125
Mailing Address - Country:US
Mailing Address - Phone:606-528-0283
Mailing Address - Fax:606-528-8422
Practice Address - Street 1:965 S HIGHWAY 25 W
Practice Address - Street 2:STE 52
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1608
Practice Address - Country:US
Practice Address - Phone:606-549-2588
Practice Address - Fax:606-549-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4464P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001098Medicaid
KY6383Medicare ID - Type Unspecified
KY35001098Medicaid