Healthcare Provider Details

I. General information

NPI: 1215470224
Provider Name (Legal Business Name): JOURNEYPURE KENTUCKY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 RUSSELLVILLE RD
BOWLING GREEN KY
42101-3986
US

IV. Provider business mailing address

5500 MARYLAND WAY SUITE 200
BRENTWOOD TN
37027-7048
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-3387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KEVIN D LEE
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 615-973-3500