Provider Demographics
NPI:1942235981
Name:BREATHITT COUNTY HOME MEDICAL LLC
Entity Type:Organization
Organization Name:BREATHITT COUNTY HOME MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-693-0939
Mailing Address - Street 1:726 HIGHWAY 15 N STE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-8601
Mailing Address - Country:US
Mailing Address - Phone:606-693-0939
Mailing Address - Fax:606-693-0938
Practice Address - Street 1:726 HIGHWAY 15 N STE 2
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-693-0939
Practice Address - Fax:606-693-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYMG0424332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90060138Medicaid
KY90060138Medicaid