1053382788 NPI number — MEDICAL INVESTMENT TRUST

Table of content: (NPI 1053382788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053382788 NPI number — MEDICAL INVESTMENT TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL INVESTMENT TRUST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASTHMA AND ALLERGY CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053382788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2708
Provider Second Line Business Mailing Address:
ASTHMA AND ALLERGY CENTER
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41502-2708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-432-0174
Provider Business Mailing Address Fax Number:
606-437-0438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
156 ISLAND CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41501-9340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-432-0174
Provider Business Practice Location Address Fax Number:
606-437-0438
Provider Enumeration Date:
01/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SO
Authorized Official First Name:
DJIEN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
606-432-0174

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  17816 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 3001627 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 65-922866 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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