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General NPI Number Information
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NPI Number | 1053382788
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Entity Type | Organization
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Legal Business Name | MEDICAL INVESTMENT TRUST
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Dates
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Enumeration Date | 01/31/2006
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Last Update Date | 09/13/2024
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Provider Practice Location Address
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Address Line | 156 ISLAND CREEK RD
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City | PIKEVILLE
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State | KY
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Zip | 41501-9340
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Country | US
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Telephone | 606-432-0174
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Fax | 606-437-0438
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Provider Business Mailing Address
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Address Line | PO BOX 2708 ASTHMA AND ALLERGY CENTER
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City | PIKEVILLE
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State | KY
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Zip | 41502-2708
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Country | US
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Telephone | 606-432-0174
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Fax | 606-437-0438
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DJIEN H SO
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Credential |
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Telephone | 606-432-0174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3001627
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 17816
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License Number State | KY
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