1851957252 NPI number — PARK DUVALLE COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1851957252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851957252 NPI number — PARK DUVALLE COMMUNITY HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK DUVALLE COMMUNITY HEALTH CENTER, INC
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:
HENRY COUNTY COMMUNITY HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1851957252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3015 WILSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40211-1969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-774-4401
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMINENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40019-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-772-5034
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
JETT
Authorized Official First Name:
SWANNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
502-774-4401

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31000011 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31000920 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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