Healthcare Provider Details

I. General information

NPI: 1275549842
Provider Name (Legal Business Name): INTERVENTIONAL REHABILITATION OF KENTUCKY, P.S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E BROADWAY SUITE 250
LOUISVILLE KY
40202-3700
US

IV. Provider business mailing address

315 E BROADWAY SUITE 250
LOUISVILLE KY
40202-3700
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-4765
  • Fax: 502-589-4799
Mailing address:
  • Phone: 502-589-4765
  • Fax: 502-589-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICKY STANLEY COLLIS
Title or Position: OWNER
Credential: MD
Phone: 502-589-4765