Healthcare Provider Details

I. General information

NPI: 1811939366
Provider Name (Legal Business Name): CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CHAD ST CLOVER FORK CLINIC
EVARTS KY
40828-8200
US

IV. Provider business mailing address

101 CHAD ST PO BOX39
EVARTS KY
40828-8200
US

V. Phone/Fax

Practice location:
  • Phone: 606-837-2108
  • Fax: 606-837-9389
Mailing address:
  • Phone: 606-837-2108
  • Fax: 606-837-9389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number700006
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRITT LEWIS JR.
Title or Position: ADMINISTRATOR
Credential:
Phone: 606-837-2108