Healthcare Provider Details

I. General information

NPI: 1265159404
Provider Name (Legal Business Name): PRIMARY INJURY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2935 DOLPHIN DR STE 203
ELIZABETHTOWN KY
42701-4112
US

IV. Provider business mailing address

2935 DOLPHIN DR STE 203
ELIZABETHTOWN KY
42701-4112
US

V. Phone/Fax

Practice location:
  • Phone: 270-900-0157
  • Fax:
Mailing address:
  • Phone: 270-900-0157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRACE ROBERT KELLY
Title or Position: OWNER
Credential: DC, FNP
Phone: 502-415-3943