Provider Demographics
NPI:1922684307
Name:KENTUCKY ADDICTION CENTERS PAINTSVILLE, LLC
Entity Type:Organization
Organization Name:KENTUCKY ADDICTION CENTERS PAINTSVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CSO-HHR
Authorized Official - Prefix:
Authorized Official - First Name:TROUPER
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-324-5456
Mailing Address - Street 1:1032 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1032 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1410
Practice Address - Country:US
Practice Address - Phone:606-789-8531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty