1134738412 NPI number — HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC

Table of content: (NPI 1134738412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134738412 NPI number — HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
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:
Provider Other Organization Name Type Code:
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:
1134738412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
868 SAM PARKER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAY
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40734-6780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-269-3428
Provider Business Mailing Address Fax Number:
606-545-0366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 TREUHAFT BLVD
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
BARBOURVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40906-8300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-545-6766
Provider Business Practice Location Address Fax Number:
606-545-0366
Provider Enumeration Date:
07/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
THELMA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
APRN/OWNER
Authorized Official Telephone Number:
606-545-6766

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100663490 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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