Healthcare Provider Details

I. General information

NPI: 1427404037
Provider Name (Legal Business Name): CENTER FOR RECOVERY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W BROADWAY ST
DANVILLE KY
40422
US

IV. Provider business mailing address

300 W BROADWAY ST
DANVILLE KY
40422-1408
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-0606
  • Fax: 859-236-0066
Mailing address:
  • Phone: 859-236-0606
  • Fax: 859-236-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KHURSHEED A SIDDIQUI
Title or Position: OWNER
Credential: MD
Phone: 859-691-0201