Provider Demographics
NPI:1205284924
Name:PRIMETIME INTERVENTION
Entity type:Organization
Organization Name:PRIMETIME INTERVENTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTLAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-634-1471
Mailing Address - Street 1:20 ROYAL MELBOURNE LN
Mailing Address - Street 2:
Mailing Address - City:JENKINS
Mailing Address - State:KY
Mailing Address - Zip Code:41537-7512
Mailing Address - Country:US
Mailing Address - Phone:606-634-1471
Mailing Address - Fax:606-832-0397
Practice Address - Street 1:20 ROYAL MELBOURNE LN
Practice Address - Street 2:
Practice Address - City:JENKINS
Practice Address - State:KY
Practice Address - Zip Code:41537-7512
Practice Address - Country:US
Practice Address - Phone:606-634-1471
Practice Address - Fax:606-832-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty