Provider Demographics
NPI:1912917543
Name:KENTUCKY RIVER FOOTHILLS DEVELOPMENT COUNCIL, INC.
Entity Type:Organization
Organization Name:KENTUCKY RIVER FOOTHILLS DEVELOPMENT COUNCIL, INC.
Other - Org Name:FOOTHILLS MOBILE HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOZEFOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-624-2046
Mailing Address - Street 1:209 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1142
Mailing Address - Country:US
Mailing Address - Phone:606-663-9011
Mailing Address - Fax:606-663-9012
Practice Address - Street 1:209 RIVER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1142
Practice Address - Country:US
Practice Address - Phone:606-723-6629
Practice Address - Fax:606-723-9726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY720280261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY181856Medicare Oscar/Certification