Provider Demographics
NPI:1366800922
Name:ST. MICHAEL'S HEALTH CLINIC
Entity type:Organization
Organization Name:ST. MICHAEL'S HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP, APRN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:270-640-5821
Mailing Address - Street 1:2801 WALTER GARRETT LN.
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42262-9998
Mailing Address - Country:US
Mailing Address - Phone:270-640-5821
Mailing Address - Fax:844-270-5587
Practice Address - Street 1:2801 WALTER GARRETT LN
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:KY
Practice Address - Zip Code:42262-9998
Practice Address - Country:US
Practice Address - Phone:270-640-5821
Practice Address - Fax:844-270-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004526261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care