Provider Demographics
NPI:1710047998
Name:PURCHASE CARE LLC
Entity Type:Organization
Organization Name:PURCHASE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:270-395-5388
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029
Mailing Address - Country:US
Mailing Address - Phone:270-395-5388
Mailing Address - Fax:270-395-1792
Practice Address - Street 1:503 5TH AVE
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029
Practice Address - Country:US
Practice Address - Phone:270-395-5388
Practice Address - Fax:270-395-1792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65941718Medicaid
000000174371OtherANTHEM
KY65941718Medicaid
0924401Medicare ID - Type Unspecified