Provider Demographics
NPI:1508195041
Name:ADULT IMMUNIZATION MANAGEMENT, LLC
Entity Type:Organization
Organization Name:ADULT IMMUNIZATION MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRABTREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-663-1240
Mailing Address - Street 1:PO BOX 1221
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1221
Mailing Address - Country:US
Mailing Address - Phone:270-663-1240
Mailing Address - Fax:270-228-4400
Practice Address - Street 1:1010 ALLEN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3025
Practice Address - Country:US
Practice Address - Phone:270-663-1240
Practice Address - Fax:270-228-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100123610Medicaid
KY7100123610Medicaid