Provider Demographics
NPI:1578811774
Name:MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Entity Type:Organization
Organization Name:MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Other - Org Name:HOMEPLACE CLINIC PAINTSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PROMOD
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHNOI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-886-8572
Mailing Address - Street 1:838 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1384
Mailing Address - Country:US
Mailing Address - Phone:606-788-1345
Mailing Address - Fax:606-788-3548
Practice Address - Street 1:838 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240
Practice Address - Country:US
Practice Address - Phone:606-788-1345
Practice Address - Fax:606-788-3548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700264261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)