Provider Demographics
NPI:1093031288
Name:MOUNTAIN OUTREACH INC
Entity Type:Organization
Organization Name:MOUNTAIN OUTREACH INC
Other - Org Name:MOUNTAIN OUTREACH ADULT DAY-PIKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-639-8801
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:NEON
Mailing Address - State:KY
Mailing Address - Zip Code:41840-0271
Mailing Address - Country:US
Mailing Address - Phone:606-639-8801
Mailing Address - Fax:606-639-8779
Practice Address - Street 1:11 MITCHELL ROAD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-639-8801
Practice Address - Fax:606-639-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY750178261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1538211453Medicaid
KY1699907972Medicaid