=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578102760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST MOUNTAIN HEALTH CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3165 BLACKLOG RD
-----------------------------------------------------
City | INEZ
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41224-9113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-534-3435
-----------------------------------------------------
Fax | 606-534-3436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 389
-----------------------------------------------------
City | INEZ
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41224-0389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-534-3435
-----------------------------------------------------
Fax | 606-534-3436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO, OWNER
-----------------------------------------------------
Name | SCOTT SIEGEL
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 606-534-3435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------