Healthcare Provider Details

I. General information

NPI: 1194954875
Provider Name (Legal Business Name): ULTIMATE CARE MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 WINCHESTER AVE
ASHLAND KY
41101-2065
US

IV. Provider business mailing address

3655 WINCHESTER AVE
ASHLAND KY
41101-2065
US

V. Phone/Fax

Practice location:
  • Phone: 606-393-4632
  • Fax: 888-411-4131
Mailing address:
  • Phone: 606-393-4632
  • Fax: 888-411-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberKY-10054-M
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number810271
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number40541
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number10054
License Number StateKY

VIII. Authorized Official

Name: ROSE URADU
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 606-393-4632