Healthcare Provider Details

I. General information

NPI: 1326210709
Provider Name (Legal Business Name): WESTLAKE PRIMARY CARE OF RUSSELL COUNTY NURSING GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 LAKEWAY DRIVE
RUSSELL SPRINGS KY
42642
US

IV. Provider business mailing address

2465 LAKEWAY DRIVE
RUSSELL SPRINGS KY
42642
US

V. Phone/Fax

Practice location:
  • Phone: 270-858-3636
  • Fax: 270-858-3660
Mailing address:
  • Phone: 270-858-3636
  • Fax: 270-858-3660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3234P
License Number StateKY

VIII. Authorized Official

Name: REX A TUNGATE
Title or Position: CEO, ADMINISTRATOR
Credential:
Phone: 270-384-4753