Provider Demographics
NPI:1497195036
Name:CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
Entity Type:Organization
Organization Name:CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRITT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:606-837-2108
Mailing Address - Street 1:101 CHAD ST
Mailing Address - Street 2:BOX 39
Mailing Address - City:EVARTS
Mailing Address - State:KY
Mailing Address - Zip Code:40828-8200
Mailing Address - Country:US
Mailing Address - Phone:606-837-2108
Mailing Address - Fax:606-837-9389
Practice Address - Street 1:209 E MOUND ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-2321
Practice Address - Country:US
Practice Address - Phone:606-573-1975
Practice Address - Fax:606-837-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QF0400X
KY900168261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9188Medicare PIN