Basic Information
| Provider Information | |||||||||
| NPI: | 1497302723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTERS OF WESTERN KENTUCKY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 257 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423450257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703385777 | ||||||||
| FaxNumber: | 2703385765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1497 NASHVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707261266 | ||||||||
| FaxNumber: | 2707261961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2019 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | SWAB | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2703385777 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 31000458 | 05 | KY | MEDICAID |