| Grand Lakes Clinic | |
|
1860 Jh Obryan Ave Grand Rivers KY 42045-9049 | |
| (703) 628-2462 | |
| (270) 362-9757 |
| Full Name | Grand Lakes Clinic |
|---|---|
| Speciality | Clinic/Center |
| Location | 1860 Jh Obryan Ave, Grand Rivers, Kentucky |
| Authorized Official Name and Position | Mark A Edwards (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Contact | 2709882299 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Grand Lakes Clinic 131 Hospital Dr Salem KY 42078-8043 Ph: (270) 988-2299 | Grand Lakes Clinic 1860 Jh Obryan Ave Grand Rivers KY 42045-9049 Ph: (703) 628-2462 |
| NPI Number | 1578549184 |
|---|---|
| Provider Enumeration Date | 12/16/2005 |
| Last Update Date | 11/02/2020 |
| Medicare PECOS PAC ID | 5799692547 |
|---|---|
| Medicare Enrollment ID | O20020917000008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1578549184 | NPI | - | NPPES |
| 3500140300 | Medicaid | KY | |
| 000000072411 | Other | KY | BC/BS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QR1300X | Clinic/center - Rural Health | 9000135 (Kentucky) | Primary |
Grand Lakes Clinic Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 1860 J.h. O'bryan Ave., Grand Rivers, KY 42045 Phone: 270-362-8246 Fax: 270-362-9757 |