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General NPI Number Information
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NPI Number | 1003327412
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Entity Type | Organization
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Legal Business Name | SOUTHERN KENTUCKY PRIMARY CARE, P.S.C.
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Dates
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Enumeration Date | 10/12/2017
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Last Update Date | 06/15/2018
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Provider Practice Location Address
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Address Line | 101 W 2ND ST
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City | RUSSELLVILLE
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State | KY
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Zip | 42276
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Country | US
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Telephone | 270-881-1813
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Fax | 270-886-6600
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Provider Business Mailing Address
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Address Line | 1739 CANTON ST
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City | HOPKINSVILLE
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State | KY
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Zip | 42240-1991
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Country | US
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Telephone | 270-881-1813
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Fax | 270-886-6008
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | LATISHA EDMONDS
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Credential |
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Telephone | 270-265-2574
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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