Provider Demographics
NPI:1114426863
Name:MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Entity Type:Organization
Organization Name:MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Other - Org Name:HOMEPLACE CLINIC LOUISA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ROXANN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-886-8572
Mailing Address - Street 1:130 TOWN HILL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-6389
Mailing Address - Country:US
Mailing Address - Phone:606-638-9522
Mailing Address - Fax:606-638-3548
Practice Address - Street 1:130 TOWN HILL RD
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-6389
Practice Address - Country:US
Practice Address - Phone:606-638-9522
Practice Address - Fax:606-638-3548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-08
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700264261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)