Provider Demographics
NPI:1821346321
Name:CENTRAL KENTUCKY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:CENTRAL KENTUCKY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:859-277-7246
Mailing Address - Street 1:2375 PROFESSIONAL HEIGHTS DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3040
Mailing Address - Country:US
Mailing Address - Phone:859-277-7246
Mailing Address - Fax:859-277-0061
Practice Address - Street 1:2375 PROFESSIONAL HEIGHTS DR
Practice Address - Street 2:SUITE 240
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3040
Practice Address - Country:US
Practice Address - Phone:859-277-7246
Practice Address - Fax:859-277-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty