Provider Demographics
NPI:1558690180
Name:COLLABORATIVE CARE MEDICAL ASSOCIATES INC.
Entity Type:Organization
Organization Name:COLLABORATIVE CARE MEDICAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:L
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-439-4010
Mailing Address - Street 1:941 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1377
Mailing Address - Country:US
Mailing Address - Phone:606-439-4010
Mailing Address - Fax:606-439-0880
Practice Address - Street 1:941 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1377
Practice Address - Country:US
Practice Address - Phone:606-439-4010
Practice Address - Fax:606-439-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1120DT152W00000X
KY5556P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty