Healthcare Provider Details

I. General information

NPI: 1770935041
Provider Name (Legal Business Name): LAUREL COUNTY PHYSIATRY AND PAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 THOMPSON POYNTER RD SUITE 3
LONDON KY
40741-7280
US

IV. Provider business mailing address

130 THOMPSON POYNTER RD SUITE 3
LONDON KY
40741-7280
US

V. Phone/Fax

Practice location:
  • Phone: 606-260-8345
  • Fax: 606-260-8352
Mailing address:
  • Phone: 606-260-8345
  • Fax: 606-260-8352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number34056
License Number StateKY

VIII. Authorized Official

Name: GAY B RICHARDSON
Title or Position: MD / OWNER
Credential: M.D.
Phone: 606-260-8345