1154748986 NPI number — ACK HEALTHCARE MANAGEMENT, LLC

Table of content: (NPI 1154748986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154748986 NPI number — ACK HEALTHCARE MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACK HEALTHCARE MANAGEMENT, 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:
6
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:
1154748986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1099
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42302-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-277-5170
Provider Business Mailing Address Fax Number:
502-277-5172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISPORT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-295-3890
Provider Business Practice Location Address Fax Number:
270-295-3891
Provider Enumeration Date:
03/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
812-489-0862

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100295770 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18D2054463 . This is a "CLIA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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