Healthcare Provider Details

I. General information

NPI: 1396027058
Provider Name (Legal Business Name): BIG POPS PLACE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 CANEY FORK RD
MARTIN KY
41649-7830
US

IV. Provider business mailing address

PO BOX 1287
MARTIN KY
41649-1287
US

V. Phone/Fax

Practice location:
  • Phone: 606-434-1825
  • Fax: 606-478-6674
Mailing address:
  • Phone: 606-434-1825
  • Fax: 606-478-6674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUDITH M HALE
Title or Position: CEO
Credential:
Phone: 606-434-1825