Basic Information
Provider Information | |||||||||
NPI: | 1417063207 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IRONTON & LAWRENCE COUNTY AREA COMMUNITY ACTION ORGANIZATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KEMP FAMILY MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 305 N 5TH ST | ||||||||
Address2: |   | ||||||||
City: | IRONTON | ||||||||
State: | OH | ||||||||
PostalCode: | 456381578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405323534 | ||||||||
FaxNumber: | 7405320027 | ||||||||
Practice Location | |||||||||
Address1: | 223 CARLTON DAVIDSON LN | ||||||||
Address2: |   | ||||||||
City: | COAL GROVE | ||||||||
State: | OH | ||||||||
PostalCode: | 456382924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405323048 | ||||||||
FaxNumber: | 7405324777 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2006 | ||||||||
LastUpdateDate: | 07/07/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEWIS | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTH SERVICES | ||||||||
AuthorizedOfficialTelephone: | 7405323534 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPNP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 0980836 | 05 | OH |   | MEDICAID |