Provider Demographics
NPI:1407818628
Name:JUNIPER HEALTH INC
Entity Type:Organization
Organization Name:JUNIPER HEALTH INC
Other - Org Name:LEE COUNTY FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO, CEO, CMO
Authorized Official - Phone:606-666-9950
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:141 MAIN STREET
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0690
Mailing Address - Country:US
Mailing Address - Phone:606-464-0151
Mailing Address - Fax:606-464-1052
Practice Address - Street 1:1025 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:BEATTYVILLE
Practice Address - State:KY
Practice Address - Zip Code:41311-9249
Practice Address - Country:US
Practice Address - Phone:606-464-2401
Practice Address - Fax:606-464-3290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUNIPER HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-04
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 261QD0000X
KY700132261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY181848OtherMEDCIARE FQHC PTAN
KY31000862Medicaid
KY9521OtherMEDICARE PART B