Provider Demographics
NPI:1942606454
Name:ONE CROSS HEALTH CLINIC INC
Entity Type:Organization
Organization Name:ONE CROSS HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-403-1106
Mailing Address - Street 1:106 WINSTON WAY
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-4953
Mailing Address - Country:US
Mailing Address - Phone:270-789-0034
Mailing Address - Fax:270-789-0097
Practice Address - Street 1:106 WINSTON WAY
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-4953
Practice Address - Country:US
Practice Address - Phone:270-789-0034
Practice Address - Fax:270-789-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004091261Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100657890Medicaid
KYK124131OtherMEDICARE