Provider Demographics
NPI:1598425902
Name:WILD PREMA YOGA
Entity Type:Organization
Organization Name:WILD PREMA YOGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KARUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-267-3287
Mailing Address - Street 1:3300 SQUIRE OAK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1330
Mailing Address - Country:US
Mailing Address - Phone:859-267-3287
Mailing Address - Fax:
Practice Address - Street 1:148 MINI MALL DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1170
Practice Address - Country:US
Practice Address - Phone:859-267-3287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service