Provider Demographics
NPI:1003327412
Name:SOUTHERN KENTUCKY PRIMARY CARE, P.S.C.
Entity Type:Organization
Organization Name:SOUTHERN KENTUCKY PRIMARY CARE, P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-265-2574
Mailing Address - Street 1:1739 CANTON ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1991
Mailing Address - Country:US
Mailing Address - Phone:270-881-1813
Mailing Address - Fax:270-886-6008
Practice Address - Street 1:101 W 2ND ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276
Practice Address - Country:US
Practice Address - Phone:270-881-1813
Practice Address - Fax:270-886-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-12
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty