Healthcare Provider Details

I. General information

NPI: 1023517679
Provider Name (Legal Business Name): MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

IV. Provider business mailing address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

V. Phone/Fax

Practice location:
  • Phone: 606-886-8572
  • Fax: 606-886-4433
Mailing address:
  • Phone: 606-886-8572
  • Fax: 606-886-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number700264
License Number StateKY

VIII. Authorized Official

Name: ROXANN CORDIAL
Title or Position: CREDENTIALING
Credential:
Phone: 606-886-8572