Healthcare Provider Details

I. General information

NPI: 1568230357
Provider Name (Legal Business Name): REGINALD RUSSELL OWENS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W BROADWAY
LOUISVILLE KY
40203-3607
US

IV. Provider business mailing address

545 S 2ND ST
LOUISVILLE KY
40202-1801
US

V. Phone/Fax

Practice location:
  • Phone: 502-935-9622
  • Fax:
Mailing address:
  • Phone: 502-587-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: