Provider Demographics
NPI:1477092260
Name:BLUEGRASS OUTPATIENT CENTER OF BOWLING GREEN, LLC
Entity Type:Organization
Organization Name:BLUEGRASS OUTPATIENT CENTER OF BOWLING GREEN, LLC
Other - Org Name:BLUEGRASS OUTPATIENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-745-1500
Mailing Address - Street 1:PO BOX 896114
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6114
Mailing Address - Country:US
Mailing Address - Phone:270-586-8947
Mailing Address - Fax:270-713-0234
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2370
Practice Address - Country:US
Practice Address - Phone:270-586-8947
Practice Address - Fax:270-713-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100615261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation