Healthcare Provider Details

I. General information

NPI: 1467848416
Provider Name (Legal Business Name): ENSITE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 BROADWAY ST
PADUCAH KY
42001-6869
US

IV. Provider business mailing address

611 BROADWAY ST
PADUCAH KY
42001-6869
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-1201
  • Fax:
Mailing address:
  • Phone: 270-443-1201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name: RANDALL W DURBIN
Title or Position: OWNER
Credential:
Phone: 270-443-1201