Healthcare Provider Details

I. General information

NPI: 1780102301
Provider Name (Legal Business Name): COMMUNTIY HEALTHCARE OF WESTERN KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 SOUTH WASHINGTON STREET SUITE 200
CLINTON KY
42031
US

IV. Provider business mailing address

308 SOUTH WASHINGTON STREET SUITE 200
CLINTON KY
42031-1347
US

V. Phone/Fax

Practice location:
  • Phone: 270-653-0220
  • Fax: 270-653-0221
Mailing address:
  • Phone: 270-653-0220
  • Fax: 270-653-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. STEPHANNIE LORENE GOODRUM
Title or Position: OWNER
Credential: RN
Phone: 270-653-0220