Provider Demographics
NPI:1356628648
Name:WELLNESS CENTER OF ELKHORN CITY
Entity Type:Organization
Organization Name:WELLNESS CENTER OF ELKHORN CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:606-754-3131
Mailing Address - Street 1:PO BOX 1412
Mailing Address - Street 2:
Mailing Address - City:ELKHORN CITY
Mailing Address - State:KY
Mailing Address - Zip Code:41522-1412
Mailing Address - Country:US
Mailing Address - Phone:606-754-3131
Mailing Address - Fax:606-754-4554
Practice Address - Street 1:17401 HWY 80E
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522
Practice Address - Country:US
Practice Address - Phone:606-754-3131
Practice Address - Fax:606-754-4554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center