Healthcare Provider Details

I. General information

NPI: 1114936739
Provider Name (Legal Business Name): BLUEGRASS NUTRITION COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 W 2ND ST SUITE 207
LEXINGTON KY
40508-9002
US

IV. Provider business mailing address

535 W 2ND ST SUITE 207
LEXINGTON KY
40508-9002
US

V. Phone/Fax

Practice location:
  • Phone: 859-388-9152
  • Fax: 859-255-5385
Mailing address:
  • Phone: 859-388-9152
  • Fax: 859-255-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0172
License Number StateKY

VIII. Authorized Official

Name: TINA THOMPSON
Title or Position: OWNER
Credential: RD
Phone: 859-388-9152