Basic Information
| Provider Information | |||||||||
| NPI: | 1891990693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLMONT PHYSICIAN SERVICES DBA JENKINS FAMILY CARE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JENKINS FAMILY CARE CTR, VIRGIE FAMILY MEDICAL CTR, ELKHORN CITY CLINI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37024 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Practice Location | |||||||||
| Address1: | 9480 HIGHWAY 805 | ||||||||
| Address2: | |||||||||
| City: | JENKINS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068322171 | ||||||||
| FaxNumber: | 6068322943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOCKE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4232243250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC, CCS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.