=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427336635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DREZ ONE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2011
-----------------------------------------------------
Last Update Date | 09/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 MEDPARK DR
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-263-2912
-----------------------------------------------------
Fax | 606-451-0397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 MEDPARK DR
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-263-2912
-----------------------------------------------------
Fax | 606-451-0397
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ANGIE G MAYBRIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 606-263-2912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | 27637
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------