Healthcare Provider Details

I. General information

NPI: 1164460051
Provider Name (Legal Business Name): EASTERN KENTUCKY UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 VERSAILLES RD SUITE 120
LEXINGTON KY
40504-1117
US

IV. Provider business mailing address

1306 VERSAILLES RD SUITE 120
LEXINGTON KY
40504-1117
US

V. Phone/Fax

Practice location:
  • Phone: 859-259-0717
  • Fax: 859-254-7874
Mailing address:
  • Phone: 859-259-0717
  • Fax: 859-254-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number700160
License Number StateKY

VIII. Authorized Official

Name: DR. SUSAN G. FISTER
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D
Phone: 859-259-0717