Provider Demographics
NPI:1063675866
Name:SOUTH CENTRAL KENTUCKY FOOT & ANKLE CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL KENTUCKY FOOT & ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:270-846-1900
Mailing Address - Street 1:PO BOX 1596
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-1596
Mailing Address - Country:US
Mailing Address - Phone:270-846-1900
Mailing Address - Fax:270-846-2919
Practice Address - Street 1:843 FAIRVEW AVENUE
Practice Address - Street 2:SUITE B5
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4914
Practice Address - Country:US
Practice Address - Phone:270-846-1900
Practice Address - Fax:270-846-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY234213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90013897OtherKY HEALTH CHOICES- DME