Healthcare Provider Details

I. General information

NPI: 1215276282
Provider Name (Legal Business Name): DENALI IOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 GRIFFITH AVE
OWENSBORO KY
42301-2816
US

IV. Provider business mailing address

1211 GRIFFITH AVE
OWENSBORO KY
42301-2816
US

V. Phone/Fax

Practice location:
  • Phone: 270-929-4141
  • Fax:
Mailing address:
  • Phone: 270-929-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number984616
License Number StateAK

VIII. Authorized Official

Name: JOHN D HAYDEN
Title or Position: PRESIDENT
Credential:
Phone: 270-929-4141