Healthcare Provider Details

I. General information

NPI: 1639312473
Provider Name (Legal Business Name): BLUEGRASS PEDIATRIC THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 HENDERSON DR
LEXINGTON KY
40515-6464
US

IV. Provider business mailing address

856 HENDERSON DR
LEXINGTON KY
40515-6464
US

V. Phone/Fax

Practice location:
  • Phone: 859-539-2844
  • Fax: 859-272-7311
Mailing address:
  • Phone: 859-539-2844
  • Fax: 859-272-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberR2280
License Number StateKY

VIII. Authorized Official

Name: MRS. ANGELA FULKERSON FOLCZYK
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 859-539-2844