Basic Information
| Provider Information | |||||||||
| NPI: | 1306376306 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACE COMMUNITY HEALTH CENTER INC | ||||||||
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| OtherOrganizationName: | PAGE SCHOOL BASED HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1019 CUMBERLAND FALLS HWY | ||||||||
| Address2: | SUITE B201 | ||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407012735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065454866 | ||||||||
| FaxNumber: | 6065454863 | ||||||||
| Practice Location | |||||||||
| Address1: | 239 PAGE SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409778775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063378330 | ||||||||
| FaxNumber: | 6065268606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | STANLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6065269005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GRACE COMMUNITY HEALTH CENTER INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QF0400X | 700188 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.