Provider Demographics
NPI:1043257827
Name:MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Entity Type:Organization
Organization Name:MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:L.M. (MIKE)
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-633-4823
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:606-633-1874
Practice Address - Street 1:826 KY 11 N
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41314-9155
Practice Address - Country:US
Practice Address - Phone:606-593-6395
Practice Address - Fax:606-593-5916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000169Medicaid
KY2907Medicare PIN
KY181832Medicare PIN