Healthcare Provider Details

I. General information

NPI: 1942463096
Provider Name (Legal Business Name): PRIMARY CARE OF THE BLUEGRASS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

Provider Other Name: CRAB ORCHARD PRIMARY CARE

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 MAIN ST
CRAB ORCHARD KY
40419-6548
US

IV. Provider business mailing address

1031 WELLINGTON WAY STE 240
LEXINGTON KY
40513-1257
US

V. Phone/Fax

Practice location:
  • Phone: 606-355-7800
  • Fax: 606-355-7803
Mailing address:
  • Phone: 859-303-8746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number700193
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number900266
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY UNDERWOOD
Title or Position: CREDENTIALING AGENT
Credential: DO
Phone: 859-303-8746