Provider Demographics
NPI:1326440637
Name:KENTUCKY MEDICAL SPA
Entity Type:Organization
Organization Name:KENTUCKY MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-788-1035
Mailing Address - Street 1:PO BOX 2710
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-6710
Mailing Address - Country:US
Mailing Address - Phone:606-788-1035
Mailing Address - Fax:606-788-1045
Practice Address - Street 1:636 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1349
Practice Address - Country:US
Practice Address - Phone:606-788-1035
Practice Address - Fax:606-788-1045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14390261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care