Healthcare Provider Details

I. General information

NPI: 1891294336
Provider Name (Legal Business Name): NANNCOH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2018
Last Update Date: 02/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 ENVOY CIR STE 702
LOUISVILLE KY
40299-1812
US

IV. Provider business mailing address

700 ENVOY CIR STE 702
LOUISVILLE KY
40299-1812
US

V. Phone/Fax

Practice location:
  • Phone: 502-551-2460
  • Fax: 502-896-6977
Mailing address:
  • Phone: 502-551-2460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRUCE M COHEN
Title or Position: PRESIDENT
Credential:
Phone: 502-551-2460