Provider Demographics
NPI:1720552334
Name:NICHOLASVILLE FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:NICHOLASVILLE FAMILY CHIROPRACTIC
Other - Org Name:BLUEGRASS CHIRO NICHOLASVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-408-5440
Mailing Address - Street 1:457 KEENE CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1492
Mailing Address - Country:US
Mailing Address - Phone:859-241-6003
Mailing Address - Fax:859-241-6071
Practice Address - Street 1:457 KEENE CENTRE DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1492
Practice Address - Country:US
Practice Address - Phone:592-416-0038
Practice Address - Fax:859-241-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100581450Medicaid