Healthcare Provider Details

I. General information

NPI: 1750635926
Provider Name (Legal Business Name): BUC CRESCENT SPRINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2327 BUTTERMILK XING
CRESCENT SPRINGS KY
41017-1622
US

IV. Provider business mailing address

2327 BUTTERMILK XING
CRESCENT SPRINGS KY
41017-1622
US

V. Phone/Fax

Practice location:
  • Phone: 859-344-7900
  • Fax: 859-344-0099
Mailing address:
  • Phone: 859-344-7900
  • Fax: 859-344-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROBERT R SO
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 859-344-7900