Basic Information
| Provider Information | |||||||||
| NPI: | 1306431614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEWIS COUNTY PRIMARY CARE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411790550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 TUCKER DR | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067590002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2021 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | UGRIN | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6067963029 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEWIS COUNTY PRIMARY CARE CENTER, INC. | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.