Provider Demographics
NPI:1376648139
Name:EAST KY HEALTH SERVICE CENTER
Entity type:Organization
Organization Name:EAST KY HEALTH SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:606-785-3164
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:566 HWY 899
Mailing Address - City:HINDMAN
Mailing Address - State:KY
Mailing Address - Zip Code:41822-0849
Mailing Address - Country:US
Mailing Address - Phone:606-785-3164
Mailing Address - Fax:606-785-0107
Practice Address - Street 1:566 HIGHWAY 899
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822-0849
Practice Address - Country:US
Practice Address - Phone:606-785-3164
Practice Address - Fax:606-785-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6629261QD0000X
KY700002261QP2300X
KY3008325363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65924300Medicaid
KY65924300Medicaid