Healthcare Provider Details

I. General information

NPI: 1962847475
Provider Name (Legal Business Name): NKY MED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 MADISON AVE
COVINGTON KY
41011-3330
US

IV. Provider business mailing address

1717 MADISON AVE
COVINGTON KY
41011-3330
US

V. Phone/Fax

Practice location:
  • Phone: 859-613-3722
  • Fax:
Mailing address:
  • Phone: 859-613-3722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateKY

VIII. Authorized Official

Name: MR. GARY DAVID GAVORNIK
Title or Position: DIRECTOR OF DEVELOPMENT
Credential:
Phone: 908-619-0346