Healthcare Provider Details

I. General information

NPI: 1518239862
Provider Name (Legal Business Name): CPCFS/ROBERT FANE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 LEHMAN AVE SUITE 103
BOWLING GREEN KY
42103-6515
US

IV. Provider business mailing address

1011 LEHMAN AVE SUITE 103
BOWLING GREEN KY
42103-6515
US

V. Phone/Fax

Practice location:
  • Phone: 270-393-9833
  • Fax: 270-393-9835
Mailing address:
  • Phone: 270-393-9833
  • Fax: 270-393-9835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT BRUCE FANE
Title or Position: OWNER
Credential: PH.D
Phone: 270-393-9833