1629536206 NPI number — SAMARITAN FAMILY CARE LLC

Table of content: (NPI 1629536206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629536206 NPI number — SAMARITAN FAMILY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMARITAN FAMILY 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:
1629536206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 697
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESTONSBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41653-0697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-874-2300
Provider Business Mailing Address Fax Number:
606-874-2888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 BROADWAY ST STE 301A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-372-1234
Provider Business Practice Location Address Fax Number:
606-372-1240
Provider Enumeration Date:
03/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HANA
Authorized Official First Name:
ANTOIN
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-349-8100

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7100600430 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100600040 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100702010 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100712610 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100730130 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100706120 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100596740 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100727750 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100729800 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100600030 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100730140 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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