Healthcare Provider Details

I. General information

NPI: 1437340346
Provider Name (Legal Business Name): WAYNESBURG CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14098 KY HIGHWAY 27 SOUTH
WAYNESBURG KY
40489
US

IV. Provider business mailing address

PO BOX 330
STANFORD KY
40484-0330
US

V. Phone/Fax

Practice location:
  • Phone: 606-379-6646
  • Fax: 606-379-5707
Mailing address:
  • Phone: 606-379-6646
  • Fax: 606-379-5707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name: MR. CHRISTOPHER DUVALL SIMS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 606-365-1547