Healthcare Provider Details

I. General information

NPI: 1932652765
Provider Name (Legal Business Name): DOUG MEANS MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 KIRKWOOD GLEN CIR
LOUISVILLE KY
40207-3245
US

IV. Provider business mailing address

312 KIRKWOOD GLEN CIR
LOUISVILLE KY
40207-3245
US

V. Phone/Fax

Practice location:
  • Phone: 502-544-0323
  • Fax:
Mailing address:
  • Phone: 502-544-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberAT204
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: