Healthcare Provider Details

I. General information

NPI: 1750243432
Provider Name (Legal Business Name): KENTUCKY WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2087 KINGS CHAPEL RD
CADIZ KY
42211
US

IV. Provider business mailing address

2915 RED HILL AVE STE A210C
COSTA MESA CA
92626-7979
US

V. Phone/Fax

Practice location:
  • Phone: 949-506-6162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: EMILY HINSON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 270-632-9871