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32 Dallas Stephens Rd Sandy Hook KY 41171-8275 | |
(606) 738-4579 | |
Not Available |
Full Name | |
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Speciality | Social Worker |
Location | 32 Dallas Stephens Rd, Sandy Hook, Kentucky |
Authorized Official Name and Position | Kristy L Moore (SOLE MEMBER) |
Authorized Official Contact | 6067384579 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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32 Dallas Stephens Rd Sandy Hook KY 41171-8275 Ph: (606) 738-4579 | 32 Dallas Stephens Rd Sandy Hook KY 41171-8275 Ph: (606) 738-4579 |
NPI Number | 1871135392 |
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Provider Enumeration Date | 10/16/2019 |
Last Update Date | 12/11/2019 |
Certification Date | 12/11/2019 |
Medicare PECOS PAC ID | 2668805565 |
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Medicare Enrollment ID | O20191206002155 |
Identifier | Type | State | Issuer |
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1871135392 | NPI | - | NPPES |
7100364630 | Medicaid | KY |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
Provider Name | Kristy L Moore |
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Provider Type | Practitioner - Clinical Social Worker |
Provider Identifiers | NPI Number: 1275903528 PECOS PAC ID: 8325348501 Enrollment ID: I20151119000502 |