Healthcare Provider Details

I. General information

NPI: 1356695100
Provider Name (Legal Business Name): NEW LIFE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 08/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 N MAIN ST
NICHOLASVILLE KY
40356
US

IV. Provider business mailing address

506 N MAIN ST
NICHOLASVILLE KY
40356
US

V. Phone/Fax

Practice location:
  • Phone: 859-887-3712
  • Fax: 859-887-2926
Mailing address:
  • Phone: 859-887-3712
  • Fax: 859-887-2926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JACK KENDRICK
Title or Position: PROGRAM DIRECTOR
Credential: MD
Phone: 859-887-3712