Healthcare Provider Details

I. General information

NPI: 1104937440
Provider Name (Legal Business Name): EREK RAND GILLESPIE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BRULE ST BLDG 871
FORT KNOX KY
40121-6100
US

IV. Provider business mailing address

6832 WINDHAM PKWY
PROSPECT KY
40059-8878
US

V. Phone/Fax

Practice location:
  • Phone: 502-626-9733
  • Fax:
Mailing address:
  • Phone: 502-612-7530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number5406
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: