Healthcare Provider Details

I. General information

NPI: 1255895850
Provider Name (Legal Business Name): COMMUNITY HEALTH CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 WOODLAND DR
ELIZABETHTOWN KY
42701-2749
US

IV. Provider business mailing address

1113 WOODLAND DR
ELIZABETHTOWN KY
42701-2749
US

V. Phone/Fax

Practice location:
  • Phone: 270-763-9589
  • Fax: 270-763-9689
Mailing address:
  • Phone: 270-763-9589
  • Fax: 270-763-9689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA DAILEY
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 270-763-9589