Healthcare Provider Details

I. General information

NPI: 1134264799
Provider Name (Legal Business Name): ROCKCASTLE VENTURES INC. DOING BUSINESS AS ROCKCASTLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 NEWCOMB AVE
MOUNT VERNON KY
40456-2728
US

IV. Provider business mailing address

140 NEWCOMB AVE
MOUNT VERNON KY
40456-2728
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-5176
  • Fax: 606-256-4401
Mailing address:
  • Phone: 606-256-5176
  • Fax: 606-256-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA861
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4217P
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39587
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64035884
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25335
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRANDY L. BULLOCK
Title or Position: DIRECTOR
Credential:
Phone: 606-256-7761