1366227555 NPI number — PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC

Table of content: CAMERON ROULEAU (NPI 1487432902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366227555 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:
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:
1366227555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2023
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:
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:
606-435-7642
Provider Business Mailing Address Fax Number:
606-436-5282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 HIGHWAY 119 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITESBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41858-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-439-1300
Provider Business Practice Location Address Fax Number:
606-439-1400
Provider Enumeration Date:
08/28/2023

Additional Information

Authorized Official

Authorized Official Last Name:
STRUNK
Authorized Official First Name:
RAEDAWNUA
Authorized Official Middle Name:
JADE
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
606-435-7642

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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