Provider Demographics
NPI:1053646745
Name:PRESTONSBURG HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:PRESTONSBURG HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HAZELTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-886-3077
Mailing Address - Street 1:115 WALLEN DR
Mailing Address - Street 2:
Mailing Address - City:VAN LEAR
Mailing Address - State:KY
Mailing Address - Zip Code:41265-9045
Mailing Address - Country:US
Mailing Address - Phone:606-886-3077
Mailing Address - Fax:606-886-3078
Practice Address - Street 1:113 REGENCY PARK
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9127
Practice Address - Country:US
Practice Address - Phone:606-886-3077
Practice Address - Fax:606-886-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25775261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care