Basic Information
Provider Information
NPI: 1255489910
EntityType: 2
ReplacementNPI:  
OrganizationName: LEWIS COUNTY PRIMARY CARE CENTER, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: PRIMARYPLUS
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 550
Address2:  
City: VANCEBURG
State: KY
PostalCode: 411790550
CountryCode: US
TelephoneNumber: 6067963029
FaxNumber: 6067966221
Practice Location
Address1: 927 KENTON STATION DR
Address2:  
City: MAYSVILLE
State: KY
PostalCode: 410569609
CountryCode: US
TelephoneNumber: 6067963029
FaxNumber: 6067966221
Other Information
ProviderEnumerationDate: 01/08/2007
LastUpdateDate: 04/12/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: UGRIN
AuthorizedOfficialFirstName: JERRY
AuthorizedOfficialMiddleName: G
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 6067963029
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QP2300X700041KYY Ambulatory Health Care FacilitiesClinic/CenterPrimary Care

ID Information
IDTypeStateIssuerDescription
301596305OH MEDICAID


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