Healthcare Provider Details

I. General information

NPI: 1053799080
Provider Name (Legal Business Name): COMMUNITY CARE OF KENTUCKY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 S MAIN ST STE 4
MADISONVILLE KY
42431-3337
US

IV. Provider business mailing address

PO BOX 2369
ANNISTON AL
36202-2369
US

V. Phone/Fax

Practice location:
  • Phone: 270-383-5511
  • Fax: 270-821-9602
Mailing address:
  • Phone: 256-741-7340
  • Fax: 256-741-7373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENELL STUMP
Title or Position: MANAGER, LICENSING & CREDENTIALING
Credential:
Phone: 629-999-5006