Provider Demographics
NPI:1720454507
Name:PENNYROYAL HEALTHCARE SERVICES, INC.
Entity type:Organization
Organization Name:PENNYROYAL HEALTHCARE SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-365-0227
Mailing Address - Street 1:310 HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445-1622
Mailing Address - Country:US
Mailing Address - Phone:270-365-0227
Mailing Address - Fax:270-365-2559
Practice Address - Street 1:244 THOMPSONVILLE LN
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:KY
Practice Address - Zip Code:42262-8250
Practice Address - Country:US
Practice Address - Phone:270-365-2227
Practice Address - Fax:270-365-2559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty