Provider Demographics
NPI:1619339736
Name:CENTRAL KENTUCKY RECOVERY MANAGEMENT
Entity Type:Organization
Organization Name:CENTRAL KENTUCKY RECOVERY MANAGEMENT
Other - Org Name:NEW LIFE RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-569-3145
Mailing Address - Street 1:1094 US HIGHWAY 27 S STE A
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7078
Mailing Address - Country:US
Mailing Address - Phone:859-569-3145
Mailing Address - Fax:859-569-3176
Practice Address - Street 1:1094 US HIGHWAY 27 S STE A
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7078
Practice Address - Country:US
Practice Address - Phone:859-569-3145
Practice Address - Fax:859-569-3176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-28
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY810849OtherAODE LICENSE
KY7100435380Medicaid