Provider Demographics
NPI:1821482118
Name:PRACTITIONER SERVICES PLLC
Entity Type:Organization
Organization Name:PRACTITIONER SERVICES PLLC
Other - Org Name:TRU HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:REAGEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUGHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-862-8917
Mailing Address - Street 1:1102 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-1529
Mailing Address - Country:US
Mailing Address - Phone:606-770-5121
Mailing Address - Fax:606-770-5199
Practice Address - Street 1:1102 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1529
Practice Address - Country:US
Practice Address - Phone:606-770-5121
Practice Address - Fax:606-770-5199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRACTITIONER SERVICES PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-24
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYB0-3893OtherCMS CERT# FOR RURAL HEALTH CLINIC DESIGNATION
KY7100379970Medicaid
KY7100042670Medicaid