Healthcare Provider Details

I. General information

NPI: 1184657736
Provider Name (Legal Business Name): REDD ROAD ENTERPRISES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9321 KY 80-EAST
RUSSELL SPRINGS KY
42728
US

IV. Provider business mailing address

PO BOX 1430
FRANKFORT KY
40602-1430
US

V. Phone/Fax

Practice location:
  • Phone: 270-385-9208
  • Fax: 270-385-9209
Mailing address:
  • Phone: 502-226-3858
  • Fax: 502-223-9829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD J. WEIDLER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-385-9208