Provider Demographics
NPI:1154065324
Name:COMMUNITY HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-763-9589
Mailing Address - Street 1:1113 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2749
Mailing Address - Country:US
Mailing Address - Phone:270-763-9589
Mailing Address - Fax:270-763-9689
Practice Address - Street 1:1113 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2749
Practice Address - Country:US
Practice Address - Phone:270-763-9589
Practice Address - Fax:270-763-9689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100744700Medicaid