Provider Demographics
NPI:1568094670
Name:COMMONWEALTH COMMUNITY CARE CENTERS, LLC
Entity Type:Organization
Organization Name:COMMONWEALTH COMMUNITY CARE CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISENER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:256-258-9603
Mailing Address - Street 1:156 NORTH LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRESTONBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653
Mailing Address - Country:US
Mailing Address - Phone:606-506-5093
Mailing Address - Fax:606-506-5039
Practice Address - Street 1:154 N LAKE DR
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1270
Practice Address - Country:US
Practice Address - Phone:606-506-5093
Practice Address - Fax:606-506-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty