Provider Demographics
NPI:1992197867
Name:BC MEDICAL LLC
Entity Type:Organization
Organization Name:BC MEDICAL LLC
Other - Org Name:CONVENIENT CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/NP
Authorized Official - Prefix:MS
Authorized Official - First Name:NADINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-330-1717
Mailing Address - Street 1:1675 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2050
Mailing Address - Country:US
Mailing Address - Phone:606-330-1717
Mailing Address - Fax:606-330-0061
Practice Address - Street 1:1675 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2050
Practice Address - Country:US
Practice Address - Phone:606-330-1717
Practice Address - Fax:606-330-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005556363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100058050Medicaid