Healthcare Provider Details

I. General information

NPI: 1942554068
Provider Name (Legal Business Name): PRESTONSBURG PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 N LAKE DR
PRESTONSBURG KY
41653-1278
US

IV. Provider business mailing address

535 N LAKE DR
PRESTONSBURG KY
41653-1278
US

V. Phone/Fax

Practice location:
  • Phone: 606-886-8466
  • Fax: 606-886-0250
Mailing address:
  • Phone: 606-886-8466
  • Fax: 606-886-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name: DR. BLAKE R BURCHETT
Title or Position: MEMBER
Credential: MD
Phone: 606-886-8466