Healthcare Provider Details

I. General information

NPI: 1386057818
Provider Name (Legal Business Name): ADIAVNI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 CUMBERLAND TRACE RD APT. 417
BOWLING GREEN KY
42103-9099
US

IV. Provider business mailing address

280 CUMBERLAND TRACE RD APT. 417
BOWLING GREEN KY
42103-9099
US

V. Phone/Fax

Practice location:
  • Phone: 815-220-9028
  • Fax: 815-220-9028
Mailing address:
  • Phone: 815-220-9028
  • Fax: 815-220-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: ANIL ARORA
Title or Position: OWNER
Credential: MD
Phone: 815-220-9028