Healthcare Provider Details

I. General information

NPI: 1952706111
Provider Name (Legal Business Name): ADDIXXION RECOVERY OF KENTUCKY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BELINDA BLVD
DANVILLE KY
40422-3217
US

IV. Provider business mailing address

461 S 4TH ST
DANVILLE KY
40422-2053
US

V. Phone/Fax

Practice location:
  • Phone: 859-209-2320
  • Fax:
Mailing address:
  • Phone: 859-209-2305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. GINGER JACKSON
Title or Position: MARKETING
Credential:
Phone: 859-333-5125