Provider Demographics
NPI:1457303802
Name:LEWIS COUNTY PRIMARY CARE CENTER
Entity Type:Organization
Organization Name:LEWIS COUNTY PRIMARY CARE CENTER
Other - Org Name:PRIMARYPLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:UGRIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-796-3029
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-0550
Mailing Address - Country:US
Mailing Address - Phone:606-796-3029
Mailing Address - Fax:606-796-6221
Practice Address - Street 1:211 KY 59
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-9719
Practice Address - Country:US
Practice Address - Phone:606-796-3029
Practice Address - Fax:606-796-6221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700041261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000268Medicaid
OH0864613Medicaid
KY181818Medicare Oscar/Certification
KY0556Medicare PIN