Provider Demographics
NPI:1245236900
Name:BRECKINRIDGE HEALTH, INC.
Entity Type:Organization
Organization Name:BRECKINRIDGE HEALTH, INC.
Other - Org Name:CLOVERPORT HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:270-788-3000
Mailing Address - Street 1:209 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERPORT
Mailing Address - State:KY
Mailing Address - Zip Code:40111-1324
Mailing Address - Country:US
Mailing Address - Phone:270-788-3000
Mailing Address - Fax:270-788-6201
Practice Address - Street 1:209 ELM ST
Practice Address - Street 2:
Practice Address - City:CLOVERPORT
Practice Address - State:KY
Practice Address - Zip Code:40111-1324
Practice Address - Country:US
Practice Address - Phone:270-788-3000
Practice Address - Fax:270-788-6201
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRECKINRIDGE HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-27
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900053261Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35000587Medicaid
KY1049478OtherPASSPORT
KY35000587Medicaid