Healthcare Provider Details

I. General information

NPI: 1760017180
Provider Name (Legal Business Name): INTEGRATIVE HEALTH CENTERS OF KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1894 CEDAR ST
MC KENZIE TN
38201-2206
US

IV. Provider business mailing address

1105 16TH AVE S STE C
NASHVILLE TN
37212-2327
US

V. Phone/Fax

Practice location:
  • Phone: 731-352-0603
  • Fax:
Mailing address:
  • Phone: 615-521-9097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL CAUDILL
Title or Position: PRESIDENT
Credential:
Phone: 615-521-9097