Healthcare Provider Details

I. General information

NPI: 1023482353
Provider Name (Legal Business Name): KENTUCKY MEDICAL SERVICES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 W PALMETTO PARK RD STE 205
BOCA RATON FL
33433-3430
US

IV. Provider business mailing address

3945 PEPPERTREE DR
LEXINGTON KY
40513-1398
US

V. Phone/Fax

Practice location:
  • Phone: 855-200-8262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number38090
License Number StateKY

VIII. Authorized Official

Name: ERIC GLINIECKI
Title or Position: DIRECTOR
Credential:
Phone: 855-200-8262