Healthcare Provider Details

I. General information

NPI: 1891303368
Provider Name (Legal Business Name): 1025 HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HARDIN LN
SOMERSET KY
42503-3818
US

IV. Provider business mailing address

110 HARDIN LN
SOMERSET KY
42503-3818
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-9748
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT JOHNSON
Title or Position: NP
Credential: APRN
Phone: 606-451-9748