Provider Demographics
NPI:1962847475
Name:NKY MED, LLC
Entity Type:Organization
Organization Name:NKY MED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GAVORNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-619-0346
Mailing Address - Street 1:1717 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3330
Mailing Address - Country:US
Mailing Address - Phone:859-613-3722
Mailing Address - Fax:
Practice Address - Street 1:1717 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3330
Practice Address - Country:US
Practice Address - Phone:859-613-3722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone