Healthcare Provider Details

I. General information

NPI: 1588012488
Provider Name (Legal Business Name): EAST COAST REHABILITATION CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 EXECUTIVE PARK
ST MATTHEWS KY
40207-4205
US

IV. Provider business mailing address

512 EXECUTIVE PARK
ST MATTHEWS KY
40207-4205
US

V. Phone/Fax

Practice location:
  • Phone: 502-415-9289
  • Fax:
Mailing address:
  • Phone: 502-415-9289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberADCLAD00222794
License Number StateKY

VIII. Authorized Official

Name: MR. BENJAMIN D FERGUSON IV
Title or Position: MEMBER
Credential: LCADC
Phone: 606-369-4617