Healthcare Provider Details

I. General information

NPI: 1053647313
Provider Name (Legal Business Name): EASTERN KENTUCKY PAIN MANAGEMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1694 NORTHGATE DR
RICHMOND KY
40475-1066
US

IV. Provider business mailing address

1694 NORTHGATE DR
RICHMOND KY
40475-1066
US

V. Phone/Fax

Practice location:
  • Phone: 859-626-7755
  • Fax: 859-626-7766
Mailing address:
  • Phone: 859-626-7755
  • Fax: 859-626-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: BRAD HAMBLEN
Title or Position: MEMBER
Credential:
Phone: 859-746-2444