Healthcare Provider Details

I. General information

NPI: 1790909075
Provider Name (Legal Business Name): TERESA BLAIR RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 NEWCOMB AVE. ROCKCASTLE HOSPITAL
MT VERNON KY
40456
US

IV. Provider business mailing address

59 STEPHENS RD.
MT VERNON KY
40456
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-7718
  • Fax:
Mailing address:
  • Phone: 606-256-9132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberKY 0803
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: