1194954875 NPI number — ULTIMATE CARE MEDICAL SERVICES LLC

Table of content: (NPI 1194954875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194954875 NPI number — ULTIMATE CARE MEDICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ULTIMATE CARE MEDICAL SERVICES 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:
ULTIMATE TREATMENT 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:
1194954875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3655 WINCHESTER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41101-2065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-393-4632
Provider Business Mailing Address Fax Number:
888-411-4131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3655 WINCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-2065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-393-4632
Provider Business Practice Location Address Fax Number:
888-411-4131
Provider Enumeration Date:
07/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
URADU
Authorized Official First Name:
ROSE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
606-393-4632

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  810271 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X , with the licence number: 40541 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X , with the licence number: KY-10054-M , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0002X , with the licence number: 10054 , 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: 7100090030 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1832977 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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