Healthcare Provider Details

I. General information

NPI: 1881925428
Provider Name (Legal Business Name): MNT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 TRADITIONS BLVD
BOWLING GREEN KY
42103-7957
US

IV. Provider business mailing address

207 TRADITIONS BLVD
BOWLING GREEN KY
42103-7957
US

V. Phone/Fax

Practice location:
  • Phone: 270-901-3412
  • Fax: 270-901-3413
Mailing address:
  • Phone: 270-901-3412
  • Fax: 270-901-3413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateKY

VIII. Authorized Official

Name: MR. DOUGLAS T ANDERSON
Title or Position: OWNER
Credential:
Phone: 270-901-3412