Provider Demographics
NPI:1659702660
Name:CENTRAL KENTUCKY DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:CENTRAL KENTUCKY DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:ARRT RT(R)
Authorized Official - Phone:606-305-3192
Mailing Address - Street 1:102 AGRICULTURAL WAY
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-1461
Mailing Address - Country:US
Mailing Address - Phone:606-305-3192
Mailing Address - Fax:606-365-4888
Practice Address - Street 1:102 AGRICULTURAL WAY
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-1461
Practice Address - Country:US
Practice Address - Phone:606-305-3192
Practice Address - Fax:606-365-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY730228OtherSTATE LICENSE
KY7100338650Medicaid
KY7100338650Medicaid