Healthcare Provider Details

I. General information

NPI: 1477092260
Provider Name (Legal Business Name): BLUEGRASS OUTPATIENT CENTER OF BOWLING GREEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MAIN ST
FRANKLIN KY
42134-2370
US

IV. Provider business mailing address

PO BOX 896114
CHARLOTTE NC
28289-6114
US

V. Phone/Fax

Practice location:
  • Phone: 270-586-8947
  • Fax: 270-713-0234
Mailing address:
  • Phone: 270-586-8947
  • Fax: 270-713-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number100615
License Number StateKY

VIII. Authorized Official

Name: RONALD G SOWELL
Title or Position: EXEC. VICE PRESIDENT
Credential:
Phone: 270-745-1500