Healthcare Provider Details

I. General information

NPI: 1821783259
Provider Name (Legal Business Name): BIBB ADDICTION & OBESITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 WALLER AVE STE 100
LEXINGTON KY
40504-2924
US

IV. Provider business mailing address

365 WALLER AVE STE 100
LEXINGTON KY
40504-2924
US

V. Phone/Fax

Practice location:
  • Phone: 859-309-1829
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID CARTER
Title or Position: BILLING MANAGER
Credential:
Phone: 859-737-0904