Healthcare Provider Details

I. General information

NPI: 1801047808
Provider Name (Legal Business Name): DAGAMAC ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 HOPKINSVILLE ST
GREENVILLE KY
42345-1101
US

IV. Provider business mailing address

441 HOPKINSVILLE ST
GREENVILLE KY
42345-1101
US

V. Phone/Fax

Practice location:
  • Phone: 270-338-2280
  • Fax: 270-338-0795
Mailing address:
  • Phone: 270-338-2280
  • Fax: 270-338-0795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberKY-0191
License Number StateKY

VIII. Authorized Official

Name: MR. DARRYL WADE MCINTOSH
Title or Position: COUNSELOR/THERAPIST
Credential: CADC, MACA
Phone: 270-338-2280