MEDICARE: KENTUCKY MOUNTAIN HEALTH ALLIANCE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1407043979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENTUCKY MOUNTAIN HEALTH ALLIANCE, INC.

Provider Business Mailing Address
First Line	:	279 E MAIN ST STE 300
Second Line	:
City	:	HAZARD
State	:	KY
Zip	:	41701-1920
Country	:	US
Telephone Number	:	606-487-9505
Fax Number	:	606-436-0071

Provider Business Practice Location Address
First Line	:	279 E MAIN ST
Second Line	:
City	:	HAZARD
State	:	KY
Zip	:	41701-1920
Country	:	US
Telephone Number	:	606-487-9505
Fax Number	:	606-436-0071

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. ELLEN VANCE
Credential	:
Telephone Number	:	606-487-9505

Provider Enumeration Date	:	09/28/2007
Last Update Date	:	08/20/2024

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