Healthcare Provider Details

I. General information

NPI: 1568094670
Provider Name (Legal Business Name): COMMONWEALTH COMMUNITY CARE CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 N LAKE DR
PRESTONSBURG KY
41653-1270
US

IV. Provider business mailing address

156 NORTH LAKE DRIVE
PRESTONBURG KY
41653
US

V. Phone/Fax

Practice location:
  • Phone: 606-506-5093
  • Fax: 606-506-5039
Mailing address:
  • Phone: 606-506-5093
  • Fax: 606-506-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. YVETTE WISENER
Title or Position: BILLING
Credential: CPC
Phone: 256-258-9603