Provider Demographics
NPI:1740672617
Name:PENNYROYAL HEALTHCARE SERVICES, INC
Entity type:Organization
Organization Name:PENNYROYAL HEALTHCARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-886-2205
Mailing Address - Street 1:310 HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445-1622
Mailing Address - Country:US
Mailing Address - Phone:270-365-0227
Mailing Address - Fax:270-365-2559
Practice Address - Street 1:310 HAWTHORNE ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-1622
Practice Address - Country:US
Practice Address - Phone:270-886-2205
Practice Address - Fax:270-886-0392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK037511Medicare PIN