Family Practice of Kentucky LLC
Organization Active NPI Rural Health Clinic/Center · Manchester, KY
NPI 1972979540 · NPPES record last updated Oct 3, 2022
Key facts
- NPI
- 1972979540
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- FAMILY PRACTICE OF KENTUCKY LLC
- Practice address
- 21 Crestview Dr
Manchester, KY 40962-7012 - Phone
- (606) 594-1769
- Fax
- (606) 596-0473
- NPI assigned
- Aug 18, 2015
- Organization subpart
- No
Authorized official
- Name
- Mrs. Eva A Edwards, ARNP,FNP-BC,RFNA,CNO
- Title
- Owner
- Phone
- (606) 594-1769
Owners & managing parties with NPI records 2
-
Dana Phillip Edwards, M.D.
-
Eva Angel Edwards, APRN,FNP-BC,RFNA,CNO
Practitioners 12
-
Eva Angel Edwards, APRN,FNP-BC,RFNA,CNO
-
Sandra Pennington, APRN
-
Kayla Roach, APRN
-
Betty Alevras, APRN
-
Kristina Michelle Byrd, APRN, FNP-C
-
Dana Phillip Edwards, M.D.
-
Amber Henson, APRN
-
Jill S Jones, MD
-
Tammy S. Saylor, APRN
-
Veronica L Boley, APRN
-
Natalie Nicole Gross, APRN, FNP-C
-
Deanna Swafford, LPCC
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D2120458 | Family Practice of Kentucky LLC | Certificate of waiver | Oct 17, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Rural health clinic certification: CCN 188978
- Legal name
- FAMILY PRACTICE OF KENTUCKY LLC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 19, 2018
- Last certification
- Jul 19, 2018
- Ownership / control type
- 1B
- Organization structure
- LLC · Proprietary
- Incorporated
- Aug 28, 2015 in KY
- Enrollment address
- 21 Crestview Dr
Manchester, KY 40962-7012
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| Dana P Edwards |
Corporate Director |
Aug 1, 2016 | |
| Eva a Edwards |
5% Or Greater Direct Ownership Interest | Aug 1, 2016 | 100% |
| Sheri Sizemore |
W-2 Managing Employee |
Aug 1, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20161004000230 | KY | Part B Supplier - Clinic/Group Practice | 2961790167 |
Receives reassigned benefits from 9 practitioners Practice locations: Manchester, KY; Pineville, KY |
| O20180307002698 | KY | Part a Provider - Rural Health Clinic | 2961790167 | Practice locations: Manchester, KY |
National Provider Directory
Locations
118 Grand Vue Plz
Ste 118
Hazard, KY 41701
Phone (606) 487-1646
703 S Main St
London, KY 40741
204 Town Branch Rd
#2
Manchester, KY 40962
204 Town Branch Rd
Manchester, KY 40962
Phone (606) 598-7766
21 Crestview Dr
Manchester, KY 40962
Phone (606) 594-1769
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor |
101YA0400X | KY | ||
| Family Medicine Physician |
207Q00000X | 900342 | KY | |
| Multi-Specialty Clinic/Center | 261QM1300X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes | ||
| Nurse Practitioner |
363L00000X | KY | ||
| Family Nurse Practitioner |
363LF0000X | KY |
Addresses
Primary practice location
21 Crestview Dr
Manchester, KY 40962-7012
Mailing address
204 Town Branch Rd
Manchester, KY 40962-1322
Phone (606) 596-7196
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 193200000X | Other | KY | TAXONOMY MULTI SPECIALTY |
| 188978 | Other | KY | MEDICARE PART A |
| 900342 | Other | KY | COMMONWEALTH OF KY PROVISIONAL LICENSE |
| 7100537420 | Medicaid | KY |
Other providers in Manchester, KY
- Family Clinic Manchaster LLC
- Family Health Care Associates
- Family Health Care Associates of Kentucky, Inc.
- Family Home Care,Inc.
- Family Medical Care of Manchester
- Tonya Lynn Farmer
- Federal Correctional Insitution
- Fortitude Recovery Center
- Frontier Nursing Healthcare, Inc.
- Jennifer L Gates
All providers in Manchester, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 3, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.