Provider Demographics
NPI:1871267252
Name:KENTUCKY ORTHOPAEDICS & SPINE PLLC
Entity Type:Organization
Organization Name:KENTUCKY ORTHOPAEDICS & SPINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEVENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-523-6695
Mailing Address - Street 1:404 SHOPPERS DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1301
Mailing Address - Country:US
Mailing Address - Phone:859-737-5333
Mailing Address - Fax:859-737-0070
Practice Address - Street 1:370 AMSDEN AVE STE 503
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-6928
Practice Address - Country:US
Practice Address - Phone:859-737-5333
Practice Address - Fax:859-737-0070
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENTUCKY ORTHOPAEDICS & SPINE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-09
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100794600Medicaid