Provider Demographics
NPI:1093186538
Name:JOURNEYPURE BOWLING GREEN LLC
Entity Type:Organization
Organization Name:JOURNEYPURE BOWLING GREEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARKET MANAGER/ OPERATIONS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:270-781-3387
Mailing Address - Street 1:2349 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-3986
Mailing Address - Country:US
Mailing Address - Phone:270-781-3387
Mailing Address - Fax:270-781-3407
Practice Address - Street 1:2349 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-300-7828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOURNEYPURE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-09
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY810200261QR0405X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder