Healthcare Provider Details

I. General information

NPI: 1407000276
Provider Name (Legal Business Name): WKVC OF BOWLING GREEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2008
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 DESTINY LN STE 118
BOWLING GREEN KY
42104-1066
US

IV. Provider business mailing address

711 SOUTH ST
GENEVA IL
60134-2511
US

V. Phone/Fax

Practice location:
  • Phone: 270-782-8866
  • Fax:
Mailing address:
  • Phone: 630-232-1946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. PRISCILLA E BRINKMAN
Title or Position: SOCIAL WORKER
Credential: LCSW
Phone: 630-232-1946