1598748600 NPI number — FC OF KENTUCKY INC

Table of content: (NPI 1598748600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598748600 NPI number — FC OF KENTUCKY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FC OF KENTUCKY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INTREPID USA HEALTHCARE SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598748600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14841 DALLAS PKWY STE 625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75254-7641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-542-4952
Provider Business Mailing Address Fax Number:
214-445-3902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2411 RING ROAD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-5930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-763-9242
Provider Business Practice Location Address Fax Number:
270-769-9315
Provider Enumeration Date:
11/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PARKER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CCO
Authorized Official Telephone Number:
214-445-3773

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  150080 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 374U00000X , with the licence number: 150080 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 42000125 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34000208 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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