Healthcare Provider Details

I. General information

NPI: 1134269384
Provider Name (Legal Business Name): SOUTHGATE MEDICAL OF KY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 GARRARD ST
COVINGTON KY
41011-2562
US

IV. Provider business mailing address

425 GARRARD ST
COVINGTON KY
41011-2562
US

V. Phone/Fax

Practice location:
  • Phone: 859-292-8880
  • Fax: 859-292-8923
Mailing address:
  • Phone: 859-292-8880
  • Fax: 859-292-8923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. RALPH L STACEY II
Title or Position: OWNER ADMINISTRATOR
Credential:
Phone: 859-292-8880