Healthcare Provider Details

I. General information

NPI: 1750691804
Provider Name (Legal Business Name): MRS. TONYA LAVERN HACKLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 E HWY 92
PINE KNOT KY
42635-0956
US

IV. Provider business mailing address

P.O. BOX 956
PINE KNOT KY
42635-0956
US

V. Phone/Fax

Practice location:
  • Phone: 606-354-4053
  • Fax:
Mailing address:
  • Phone: 606-354-4053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: