Provider Demographics
NPI:1588056519
Name:COMMUNITY CARE OF KENTUCKY, INC.
Entity type:Organization
Organization Name:COMMUNITY CARE OF KENTUCKY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITMORE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:256-241-3965
Mailing Address - Street 1:PO BOX 2369
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36202-2369
Mailing Address - Country:US
Mailing Address - Phone:256-241-3965
Mailing Address - Fax:
Practice Address - Street 1:200 CLINIC DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1661
Practice Address - Country:US
Practice Address - Phone:270-681-0514
Practice Address - Fax:270-681-5315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty