Provider Demographics
NPI:1972867224
Name:KENTUCKY PRIMARY MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:KENTUCKY PRIMARY MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:RANDY
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-487-0776
Mailing Address - Street 1:PO BOX 1797
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-1797
Mailing Address - Country:US
Mailing Address - Phone:606-487-0776
Mailing Address - Fax:606-487-0777
Practice Address - Street 1:311 ROY CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9486
Practice Address - Country:US
Practice Address - Phone:606-487-0776
Practice Address - Fax:606-487-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty