Basic Information
| Provider Information | |||||||||
| NPI: | 1780102301 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNTIY HEALTHCARE OF WESTERN KENTUCKY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 SOUTH WASHINGTON STREET SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420311347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706530220 | ||||||||
| FaxNumber: | 2706530221 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 SOUTH WASHINGTON STREET SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706530220 | ||||||||
| FaxNumber: | 2706530221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GOODRUM | ||||||||
| AuthorizedOfficialFirstName: | STEPHANNIE | ||||||||
| AuthorizedOfficialMiddleName: | LORENE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2706530220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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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 | 7100237310 | 05 | KY | MEDICAID | 1760722144 | 01 | KY | NPI | OTHER |