Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 17521 W Ky 9, Tollesboro, Kentucky |
Authorized Official Name and Position | Jerry Ugrin (CEO) |
Authorized Official Contact | 6067963029 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
Po Box 550 Vanceburg KY 41179-0550 Ph: (606) 796-3029 | 17521 W Ky 9 Tollesboro KY 41189 Ph: (606) 798-3151 |
NPI Number | 1205951084 |
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Provider Enumeration Date | 03/20/2007 |
Last Update Date | 01/28/2015 |
Medicare PECOS PAC ID | 1153311774 |
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Medicare Enrollment ID | O20100721000945 |
Identifier | Type | State | Issuer |
---|---|---|---|
1205951084 | NPI | - | NPPES |
31000268 | Medicaid | KY |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | 700041 (Kentucky) | Primary |