Healthcare Provider Details

I. General information

NPI: 1558690180
Provider Name (Legal Business Name): COLLABORATIVE CARE MEDICAL ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 N MAIN ST
HAZARD KY
41701-1377
US

IV. Provider business mailing address

941 N MAIN ST
HAZARD KY
41701-1377
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-4010
  • Fax: 606-439-0880
Mailing address:
  • Phone: 606-439-4010
  • Fax: 606-439-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1120DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5556P
License Number StateKY

VIII. Authorized Official

Name: DWIGHT L AVERY
Title or Position: OWNER
Credential: O.D.
Phone: 606-439-4010