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General NPI Number Information
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NPI Number | 1033314554
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Entity Type | Organization
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Legal Business Name | HEALING TABLES LTD CO
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Dates
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Enumeration Date | 06/15/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 405 FAIRFIELD AVE
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City | BELLEVUE
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State | KY
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Zip | 41073
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Country | US
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Telephone | 859-781-2328
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Fax |
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Provider Business Mailing Address
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Address Line | 405 FAIRFIELD AVE
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City | BELLEVUE
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State | KY
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Zip | 41073-1011
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Country | US
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Telephone | 859-781-2328
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Fax |
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Authorized Official
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Title or Position | OWNER.THERAPIST
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Name | MR. JERRY H CLEMONS
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Credential | LMT
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Telephone | 859-431-5777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 0420527
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License Number State | KY
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