MEDICARE: LEWIS COUNTY PRIMARY CARE CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790420214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEWIS COUNTY PRIMARY CARE CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 550
Second Line	:
City	:	VANCEBURG
State	:	KY
Zip	:	41179-0550
Country	:	US
Telephone Number	:	606-796-3029
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 MCDOWELL STREET
Second Line	:
City	:	MT. OLIVER
State	:	KY
Zip	:	41064
Country	:	US
Telephone Number	:	606-698-6160
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JERRY UGRIN
Credential	:
Telephone Number	:	606-796-3029

Provider Enumeration Date	:	04/29/2022
Last Update Date	:	04/29/2022

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