Provider Demographics
NPI:1295718757
Name:SOUTHFORK MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:SOUTHFORK MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PIMENTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-376-7212
Mailing Address - Street 1:71 MEDICAL LN
Mailing Address - Street 2:
Mailing Address - City:WHITLEY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42653-4216
Mailing Address - Country:US
Mailing Address - Phone:606-376-7212
Mailing Address - Fax:606-376-7216
Practice Address - Street 1:71 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-4216
Practice Address - Country:US
Practice Address - Phone:606-376-7212
Practice Address - Fax:606-376-7216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY07396OtherMEDICARE B
KY35001593Medicaid
KY183920Medicare PIN
KY183920Medicare Oscar/Certification