Healthcare Provider Details

I. General information

NPI: 1821546573
Provider Name (Legal Business Name): MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 ISOM PLZ
JEREMIAH KY
41826-9088
US

IV. Provider business mailing address

PO BOX 40
WHITESBURG KY
41858-0040
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-2233
  • Fax: 606-633-2223
Mailing address:
  • Phone: 606-633-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: L.M. (MIKE) CAUDILL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 606-633-4823