Provider Demographics
NPI:1134264799
Name:ROCKCASTLE VENTURES INC. DOING BUSINESS AS ROCKCASTLE CLINIC
Entity type:Organization
Organization Name:ROCKCASTLE VENTURES INC. DOING BUSINESS AS ROCKCASTLE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-256-7761
Mailing Address - Street 1:140 NEWCOMB AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-2728
Mailing Address - Country:US
Mailing Address - Phone:606-256-5176
Mailing Address - Fax:606-256-4401
Practice Address - Street 1:140 NEWCOMB AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-2728
Practice Address - Country:US
Practice Address - Phone:606-256-5176
Practice Address - Fax:606-256-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39587207Q00000X
KY64035884207Q00000X
208000000X
KYPA861363A00000X
KY4217P363L00000X
KY25335207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1881760569OtherKAREN SAYLOR NPI
KY65917437Medicaid
1649298779OtherNPI MICHAEL KEVIN ROWE
KY64035884Medicaid
1912058272OtherDAVID BULLOCK NPI
1639220916OtherGINGER MINK CASH NPI
1205988235OtherANGIE PARSON WOODS NPI
KYF13421Medicare UPIN
KY64035884Medicaid
KYQ06550Medicare UPIN
1912058272OtherDAVID BULLOCK NPI
1205988235OtherANGIE PARSON WOODS NPI
H39547Medicare UPIN