Provider Demographics
NPI:1831190115
Name:EASTERN KY TENDER CARE PEDIATRICS, LLC
Entity type:Organization
Organization Name:EASTERN KY TENDER CARE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-886-7517
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-0697
Mailing Address - Country:US
Mailing Address - Phone:606-886-7517
Mailing Address - Fax:606-886-7524
Practice Address - Street 1:5000 KY ROUTE 321
Practice Address - Street 2:SUITE 3141
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-886-7517
Practice Address - Fax:606-886-7524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000260816OtherANTHEM BCBS