Healthcare Provider Details

I. General information

NPI: 1619395605
Provider Name (Legal Business Name): WESTERN KY MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 HAMMOND PLZ
HOPKINSVILLE KY
42240-4971
US

IV. Provider business mailing address

1317 ROUTE 73 STE 200
MOUNT LAUREL NJ
08054-2202
US

V. Phone/Fax

Practice location:
  • Phone: 270-887-8333
  • Fax:
Mailing address:
  • Phone: 856-439-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number810381
License Number StateKY

VIII. Authorized Official

Name: ROBYN TANIS
Title or Position: EXECUTIVE DIRECTOR PRACTICE MGMT
Credential:
Phone: 856-533-8762