Healthcare Provider Details

I. General information

NPI: 1730352972
Provider Name (Legal Business Name): BLUEGRASS PAIN CONSULTANTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10241 CHAMPION FARMS DR
LOUISVILLE KY
40241-6150
US

IV. Provider business mailing address

10301 CHAMPION FARMS DRIVE
LOUISVILLE KY
40241-6129
US

V. Phone/Fax

Practice location:
  • Phone: 502-423-1021
  • Fax: 502-423-1416
Mailing address:
  • Phone: 502-423-1021
  • Fax: 502-423-1416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTOPHER L. NELSON
Title or Position: OWNER
Credential:
Phone: 502-423-1021