1902895527 NPI number — PERIPHERAL VASCULAR LABS OF KY, INC

Table of content: (NPI 1902895527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902895527 NPI number — PERIPHERAL VASCULAR LABS OF KY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIPHERAL VASCULAR LABS OF KY, INC
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:
1902895527
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 7039
Provider Business Mailing Address City Name:
HAZARD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41701-1381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-487-1183
Provider Business Mailing Address Fax Number:
606-436-0923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZARD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41701-1381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-487-1183
Provider Business Practice Location Address Fax Number:
606-436-0923
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLEMAN
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
606-487-1183

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 86010972 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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