Healthcare Provider Details

I. General information

NPI: 1831386192
Provider Name (Legal Business Name): EASTERN KENTUCKY UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N EAGLE CREEK SUITE 220
LEXINGTON KY
40509-1892
US

IV. Provider business mailing address

1306 VERSAILLES RD SUITE 120
LEXINGTON KY
40504-1795
US

V. Phone/Fax

Practice location:
  • Phone: 859-259-2635
  • 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 Number
License Number StateKY

VIII. Authorized Official

Name: SUSAN FISTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 859-259-0717