Healthcare Provider Details

I. General information

NPI: 1295461663
Provider Name (Legal Business Name): UNBRIDLED HEALTHCARE SYSTEM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N MAIN ST
LONDON KY
40741-1367
US

IV. Provider business mailing address

PO BOX 2448
LONDON KY
40743-2448
US

V. Phone/Fax

Practice location:
  • Phone: 606-770-3014
  • Fax:
Mailing address:
  • Phone: 606-770-3014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRI TYE
Title or Position: BILLING AND CREDENTIALING
Credential:
Phone: 606-215-3832