Healthcare Provider Details

I. General information

NPI: 1942466784
Provider Name (Legal Business Name): FIBRO CARE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 VILLAGE SQUARE DR
PADUCAH KY
42001-9060
US

IV. Provider business mailing address

PO BOX 7208
PADUCAH KY
42002-7208
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-9575
  • Fax:
Mailing address:
  • Phone: 270-415-9575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1672
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003235
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4806P
License Number StateKY

VIII. Authorized Official

Name: KIMBERLY ROMMELMAN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 270-415-9575