Provider Demographics
NPI:1023538758
Name:BLUE MOUNTAIN MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:POORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-242-2519
Mailing Address - Street 1:1814 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1229
Mailing Address - Country:US
Mailing Address - Phone:606-242-2519
Mailing Address - Fax:606-242-2520
Practice Address - Street 1:1814 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-242-2519
Practice Address - Fax:606-242-2520
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE & HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-23
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty