1164713103 NPI number — GRANT COUNTY WELLNESS CENTER LLC

Table of content: (NPI 1164713103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164713103 NPI number — GRANT COUNTY WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANT COUNTY WELLNESS CENTER 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:
1164713103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 S. MAIN ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DRY RIDGE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-325-5655
Provider Business Mailing Address Fax Number:
859-823-0530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 S. MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRY RIDGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-325-5655
Provider Business Practice Location Address Fax Number:
859-823-0530
Provider Enumeration Date:
04/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SINGLETON
Authorized Official First Name:
ERNEST
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
R.N./C.O.O.
Authorized Official Telephone Number:
859-325-5655

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  26944 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP3300X , with the licence number: 0788501.06 , 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)

  • Identifier: 208VP0000X . This is a "TAXONOMY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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