Provider Demographics
NPI:1679763049
Name:KENTUCKY CENTER FOR THE PREVENTION OF HEART ATTACK STOKE AND DIABETES
Entity Type:Organization
Organization Name:KENTUCKY CENTER FOR THE PREVENTION OF HEART ATTACK STOKE AND DIABETES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:BALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-670-8777
Mailing Address - Street 1:1214 N RACE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3462
Mailing Address - Country:US
Mailing Address - Phone:270-670-8777
Mailing Address - Fax:
Practice Address - Street 1:1214 N RACE ST
Practice Address - Street 2:SUITE B
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3462
Practice Address - Country:US
Practice Address - Phone:270-670-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00388Medicare PIN