Provider Demographics
NPI:1184676314
Name:PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC
Other - Org Name:PRIMARY CARE CENTERS OF EASTERN KENTUCKY-VICCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-439-1300
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-1988
Mailing Address - Country:US
Mailing Address - Phone:606-439-1300
Mailing Address - Fax:606-439-1400
Practice Address - Street 1:10616 S KY HWY 15
Practice Address - Street 2:SUITE A
Practice Address - City:SCUDDY
Practice Address - State:KY
Practice Address - Zip Code:41760-9033
Practice Address - Country:US
Practice Address - Phone:606-476-2274
Practice Address - Fax:606-476-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000560892OtherBC/BS
KY35002039Medicaid
KY183942Medicare Oscar/Certification
KY9844Medicare PIN