MEDICARE: WILD PREMA YOGA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1598425902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD PREMA YOGA

Provider Business Mailing Address
First Line	:	3300 SQUIRE OAK DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40515-1330
Country	:	US
Telephone Number	:	859-267-3287
Fax Number	:

Provider Business Practice Location Address
First Line	:	148 MINI MALL DR
Second Line	:
City	:	BEREA
State	:	KY
Zip	:	40403-1170
Country	:	US
Telephone Number	:	859-267-3287
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. VIVIAN KARUTZ
Credential	:
Telephone Number	:	859-267-3287

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	12/27/2021

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Directions to “WILD PREMA YOGA ” Practice Location

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