Provider Demographics
NPI:1699199422
Name:MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Entity Type:Organization
Organization Name:MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Other - Org Name:VIPER ELEMENTARY SCHOOL BASED CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:L.M.
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-633-4823
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 EDDINGTON LN
Practice Address - Street 2:SUITE 161
Practice Address - City:VIPER
Practice Address - State:KY
Practice Address - Zip Code:41774-8226
Practice Address - Country:US
Practice Address - Phone:606-633-4823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty