Provider Demographics
NPI:1477767549
Name:KAREN EASTRIDGE LLC
Entity type:Organization
Organization Name:KAREN EASTRIDGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRACTIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:EASTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:NPC, CDE
Authorized Official - Phone:502-415-2828
Mailing Address - Street 1:1553 HIGHWAY 44 E STE 2
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-7183
Mailing Address - Country:US
Mailing Address - Phone:502-921-0055
Mailing Address - Fax:502-805-0056
Practice Address - Street 1:1553 HIGHWAY 44 E STE 2
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7183
Practice Address - Country:US
Practice Address - Phone:502-921-0055
Practice Address - Fax:502-805-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3658P261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00319Medicare PIN