Provider Demographics
NPI:1932631629
Name:BLUEGRASS MOBILE MEDICAL SERVICES,LLC
Entity Type:Organization
Organization Name:BLUEGRASS MOBILE MEDICAL SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:859-797-1112
Mailing Address - Street 1:168 E REYNOLDS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-1317
Mailing Address - Country:US
Mailing Address - Phone:859-554-5067
Mailing Address - Fax:859-818-0324
Practice Address - Street 1:168 E REYNOLDS RD STE 130
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-1317
Practice Address - Country:US
Practice Address - Phone:859-554-5067
Practice Address - Fax:859-818-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-31
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1053225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100471130Medicaid