Provider Demographics
NPI:1386156610
Name:LOG MOUNTAIN FAMILY HEALTHCARE LLC
Entity type:Organization
Organization Name:LOG MOUNTAIN FAMILY HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFENY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:TREECE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-337-8887
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-0013
Mailing Address - Country:US
Mailing Address - Phone:606-337-8887
Mailing Address - Fax:
Practice Address - Street 1:101 MOUNTAIN VIEW CMNS
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-8708
Practice Address - Country:US
Practice Address - Phone:606-337-8887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOG MOUNTAIN FAMILY HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYTBDMedicaid