Provider Demographics
NPI:1093964264
Name:PALESTINE PRINCIPAL HEALTHCARE LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:PALESTINE PRINCIPAL HEALTHCARE LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-6063
Mailing Address - Street 1:680 S 4TH ST # KH3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:502-596-6063
Mailing Address - Fax:502-212-8481
Practice Address - Street 1:4000 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8467
Practice Address - Country:US
Practice Address - Phone:903-731-5398
Practice Address - Fax:903-731-4219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300202341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AMB1198Medicare PIN