Healthcare Provider Details

I. General information

NPI: 1295104800
Provider Name (Legal Business Name): COMMONWEALTH HEALTH FREE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E 10TH AVE
BOWLING GREEN KY
42101-2318
US

IV. Provider business mailing address

PO BOX 9577
BOWLING GREEN KY
42102-9577
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-9260
  • Fax: 270-782-6461
Mailing address:
  • Phone: 270-781-9260
  • Fax: 270-782-6461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD G SOWELL
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 270-745-1500