Healthcare Provider Details

I. General information

NPI: 1083397186
Provider Name (Legal Business Name): LOVELY VEINS HOLISTIC LABORATORY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N 2ND ST STE 100
RICHMOND KY
40475-1408
US

IV. Provider business mailing address

6844 BARDSTOWN RD UNIT 2144
LOUISVILLE KY
40291-3050
US

V. Phone/Fax

Practice location:
  • Phone: 502-922-6653
  • Fax:
Mailing address:
  • Phone: 502-922-6653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. BRIDGET NICOLE GORDON
Title or Position: CEO-CLINICAL DIRECTOR
Credential: A.S. FMP, CCMA, HCM,
Phone: 502-922-6653