Provider Demographics
NPI:1164713103
Name:GRANT COUNTY WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:GRANT COUNTY WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:R.N./C.O.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SINGLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-325-5655
Mailing Address - Street 1:99 S. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035
Mailing Address - Country:US
Mailing Address - Phone:859-325-5655
Mailing Address - Fax:859-823-0530
Practice Address - Street 1:99 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035
Practice Address - Country:US
Practice Address - Phone:859-325-5655
Practice Address - Fax:859-823-0530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
26944207L00000X
KY0788501.06261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY208VP0000XOtherTAXONOMY