Provider Demographics
NPI:1205018652
Name:PENNYRILE DISTRICT HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:PENNYRILE DISTRICT HEALTH DEPARTMENT
Other - Org Name:SOUTH LIVINGSTON CO MUSTANG CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PUBLIC HEALTH DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:TOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-388-9747
Mailing Address - Street 1:PO BOX 770
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42038-0770
Mailing Address - Country:US
Mailing Address - Phone:270-388-9747
Mailing Address - Fax:270-388-7749
Practice Address - Street 1:850 CUTOFF RD
Practice Address - Street 2:
Practice Address - City:SMITHLAND
Practice Address - State:KY
Practice Address - Zip Code:42081-8914
Practice Address - Country:US
Practice Address - Phone:270-928-3915
Practice Address - Fax:270-928-3915
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNYRILE DISTRICT HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100003660Medicaid