Healthcare Provider Details

I. General information

NPI: 1588434393
Provider Name (Legal Business Name): CENTRAL KENTUCKY KIDNEY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 WAR ADMIRAL STE 4
DANVILLE KY
40422-8690
US

IV. Provider business mailing address

150 WAR ADMIRAL STE 4
DANVILLE KY
40422-8690
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-6300
  • Fax:
Mailing address:
  • Phone: 859-236-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AYMAN GENEIDY
Title or Position: OWNER
Credential:
Phone: 859-236-6300