Healthcare Provider Details

I. General information

NPI: 1083397186
Provider Name (Legal Business Name): LOVELYVEINSHOLISTICLABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
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

1935 S HURSTBOURNE PKWY # 1129
LOUISVILLE KY
40220-1645
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 TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

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