Healthcare Provider Details

I. General information

NPI: 1124181508
Provider Name (Legal Business Name): ROCKCASTLE VENTURES INC. DOING BUSINESS AS MT. VERNON CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 05/21/2010
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: 606-256-4148
  • Fax:
Mailing address:
  • Phone: 606-256-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number40266
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number03104
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12635
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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