Provider Demographics
NPI:1003364373
Name:VERDANT HEALTHCARE LLC
Entity Type:Organization
Organization Name:VERDANT HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:HOWELL
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-780-3546
Mailing Address - Street 1:1300 ANDREA ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3382
Mailing Address - Country:US
Mailing Address - Phone:270-780-3546
Mailing Address - Fax:270-780-3547
Practice Address - Street 1:1300 ANDREA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3382
Practice Address - Country:US
Practice Address - Phone:270-780-3546
Practice Address - Fax:270-780-3547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40753261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100017480Medicaid
KYK216080Medicare PIN