Healthcare Provider Details

I. General information

NPI: 1477642270
Provider Name (Legal Business Name): RONALD LEE DURRETT CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 ALEXANDRIA PIKE SUITE 250
SOUTHGATE KY
41071-3290
US

IV. Provider business mailing address

20 MEDICAL VILLAGE DR SUITE 100
EDGEWOOD KY
41017-5401
US

V. Phone/Fax

Practice location:
  • Phone: 859-441-8111
  • Fax: 859-441-8111
Mailing address:
  • Phone: 859-341-7688
  • Fax: 859-341-4476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: