Provider Demographics
NPI:1346326774
Name:BEREA COLLEGE HEALTH SERVICE
Entity Type:Organization
Organization Name:BEREA COLLEGE HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:MAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-985-3212
Mailing Address - Street 1:305 ESTILL ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1742
Mailing Address - Country:US
Mailing Address - Phone:859-985-3212
Mailing Address - Fax:859-985-3910
Practice Address - Street 1:305 ESTILL ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-985-3212
Practice Address - Fax:859-985-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23321390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1353POtherJOAN MOORE, ARNP
KY1353P`OtherJOAN MOORE, ARNP
KYA72311Medicare UPIN