1184676314 NPI number — PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC

Table of content: (NPI 1184676314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184676314 NPI number — PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY CARE CENTERS OF EASTERN KENTUCKY, 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:
1184676314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1988
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
HAZARD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41702-1988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-439-1300
Provider Business Mailing Address Fax Number:
606-439-1400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10616 S KY HWY 15
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SCUDDY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41760-9033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-476-2274
Provider Business Practice Location Address Fax Number:
606-476-2304
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
606-439-1300

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000560892 . This is a "BC/BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 35002039 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com