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General NPI Number Information
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NPI Number | 1447508809
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Entity Type | Organization
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Legal Business Name | CLUBMD, LLC
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Dates
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Enumeration Date | 08/16/2012
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Last Update Date | 08/16/2012
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Provider Practice Location Address
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Address Line | 1065 ASHLEY ST SUITE 200
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City | BOWLING GREEN
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State | KY
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Zip | 42103-3400
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Country | US
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Telephone | 270-467-0010
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1094
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City | BOWLING GREEN
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State | KY
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Zip | 42102-1094
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | ERIC WARREN BLETZINGER
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Credential |
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Telephone | 270-780-2825
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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