Healthcare Provider Details

I. General information

NPI: 1275139453
Provider Name (Legal Business Name): LEWIS COUNTY PRIMARY CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 12/11/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 KENTON STATION DR
MAYSVILLE KY
41056-9613
US

IV. Provider business mailing address

PO BOX 550
VANCEBURG KY
41179-0550
US

V. Phone/Fax

Practice location:
  • Phone: 606-956-0188
  • Fax:
Mailing address:
  • Phone: 606-956-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHAD ERWIN EVANS
Title or Position: CCO
Credential:
Phone: 606-956-0188