=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306848650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH CENTERS OF WESTERN KENTUCKY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2005
-----------------------------------------------------
Last Update Date | 04/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 480 HOPKINSVILLE ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42345-1124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-338-5777
-----------------------------------------------------
Fax | 270-338-5756
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 480 HOPKINSVILLE ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42345-1124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-338-5777
-----------------------------------------------------
Fax | 270-338-5756
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ROGER ARBUCKLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-338-5777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number | 700060
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------