1770935041 NPI number — LAUREL COUNTY PHYSIATRY AND PAIN LLC

Table of content: (NPI 1770935041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770935041 NPI number — LAUREL COUNTY PHYSIATRY AND PAIN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUREL COUNTY PHYSIATRY AND PAIN LLC
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:
Provider Other Organization Name Type Code:
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:
1770935041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 THOMPSON POYNTER RD
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40741-7280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-260-8345
Provider Business Mailing Address Fax Number:
606-260-8352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 THOMPSON POYNTER RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741-7280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-260-8345
Provider Business Practice Location Address Fax Number:
606-260-8352
Provider Enumeration Date:
07/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
GAY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MD / OWNER
Authorized Official Telephone Number:
606-260-8345

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  34056 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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