Provider Demographics
NPI:1871208199
Name:LEWIS COUNTY PRIMARY CARE CENTER, INC.
Entity type:Organization
Organization Name:LEWIS COUNTY PRIMARY CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ERWIN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-956-0188
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-0550
Mailing Address - Country:US
Mailing Address - Phone:606-956-0188
Mailing Address - Fax:
Practice Address - Street 1:106 POWELL ST.
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41004
Practice Address - Country:US
Practice Address - Phone:606-402-2075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEWIS COUNTY PRIMARY CARE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000268Medicaid