Provider Demographics
NPI:1629236070
Name:MYSTYK RIVER RETREAT CENTER, LLC
Entity Type:Organization
Organization Name:MYSTYK RIVER RETREAT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARNET
Authorized Official - Middle Name:ELEANOR
Authorized Official - Last Name:WORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:502-732-9938
Mailing Address - Street 1:1732 KINGSRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:KY
Mailing Address - Zip Code:41008-8655
Mailing Address - Country:US
Mailing Address - Phone:502-732-9938
Mailing Address - Fax:502-732-9938
Practice Address - Street 1:1732 KINGSRIDGE RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-8655
Practice Address - Country:US
Practice Address - Phone:502-732-9938
Practice Address - Fax:502-732-9938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-01
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty