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General NPI Number Information
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NPI Number | 1609177021
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH QUALITY MEDICAL MANAGEMENT, LLC
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Dates
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Enumeration Date | 11/17/2010
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Last Update Date | 11/17/2010
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Provider Practice Location Address
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Address Line | 387 EDGEWOOD LN
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City | PRESTONSBURG
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State | KY
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Zip | 41653-9196
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Country | US
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Telephone | 606-769-6824
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Fax | 606-769-0086
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Provider Business Mailing Address
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Address Line | PO BOX 1747
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City | PRESTONSBURG
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State | KY
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Zip | 41653-5747
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Country | US
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Telephone | 606-769-6824
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Fax | 606-769-0086
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Authorized Official
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Title or Position | CO-OWNER
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Name | SUSAN JUSTICE
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Credential |
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Telephone | 606-769-6824
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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 |
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