Provider Demographics
NPI:1982703617
Name:SOUTHEAST KENTUCKY CLINIC
Entity Type:Organization
Organization Name:SOUTHEAST KENTUCKY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YASSER
Authorized Official - Middle Name:
Authorized Official - Last Name:NADIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-1189
Mailing Address - Street 1:402 BOGLE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2870
Mailing Address - Country:US
Mailing Address - Phone:606-679-1189
Mailing Address - Fax:
Practice Address - Street 1:402 BOGLE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2870
Practice Address - Country:US
Practice Address - Phone:606-679-1189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34018174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933681Medicaid
KY65933681Medicaid