Healthcare Provider Details

I. General information

NPI: 1598342735
Provider Name (Legal Business Name): KENTUCKY ADDICTION CENTERS WINCHESTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 TECH DR STE B
WINCHESTER KY
40391-9662
US

IV. Provider business mailing address

625 TECH DR STE B
WINCHESTER KY
40391-9662
US

V. Phone/Fax

Practice location:
  • Phone: 979-324-5456
  • Fax:
Mailing address:
  • Phone: 979-324-5456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TROUPER KRUEGER
Title or Position: CSO-HHR
Credential:
Phone: 979-324-5456