Healthcare Provider Details

I. General information

NPI: 1972205516
Provider Name (Legal Business Name): BLUEGRASS HEALTH CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 WINCHESTER AVE STE 922
ASHLAND KY
41101-7932
US

IV. Provider business mailing address

1544 WINCHESTER AVE STE 922
ASHLAND KY
41101-7932
US

V. Phone/Fax

Practice location:
  • Phone: 606-471-9423
  • Fax:
Mailing address:
  • Phone: 606-471-9423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ALEX CAIN MOORE
Title or Position: CEO
Credential: CEO
Phone: 606-471-9423