=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497165401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC WINSTEAD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2014
-----------------------------------------------------
Last Update Date | 04/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12410 HEDGEAPPLE WAY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40272-4477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-599-3331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12410 HEDGEAPPLE WAY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40272-4477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-599-3331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 2050078
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------