Healthcare Provider Details

I. General information

NPI: 1376522771
Provider Name (Legal Business Name): NRA LONDON KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 N LAUREL RD
LONDON KY
40741-6025
US

IV. Provider business mailing address

775 N LAUREL RD SUITE 500
LONDON KY
40741-6025
US

V. Phone/Fax

Practice location:
  • Phone: 606-862-8888
  • Fax: 606-862-8890
Mailing address:
  • Phone: 606-862-8888
  • Fax: 606-862-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number330159
License Number StateKY

VIII. Authorized Official

Name: MR. MARK R. FAWCETT
Title or Position: TREASURER
Credential:
Phone: 781-699-9000