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General NPI Number Information
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NPI Number | 1295385599
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Entity Type | Organization
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Legal Business Name | MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
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Dates
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Enumeration Date | 09/18/2019
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Last Update Date | 06/17/2020
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Provider Practice Location Address
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Address Line | 104 S FRONT AVE
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City | PRESTONSBURG
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State | KY
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Zip | 41653-1614
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Country | US
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Telephone | 606-886-8572
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Fax | 606-886-4433
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Provider Business Mailing Address
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Address Line | 104 S FRONT AVE
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City | PRESTONSBURG
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State | KY
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Zip | 41653-1614
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Country | US
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Telephone | 606-886-8572
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Fax | 606-886-4433
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | ROXANN CORDIAL
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Credential |
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Telephone | 606-886-8572
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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