=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497469787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NCM MOTORSPORTS PARK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2023
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 KIMBERLEE A FAST DR
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42103-7514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-467-8802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 KIMBERLEE A FAST DR
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42103-7514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-467-8802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TRACK OPERATIONS GENERAL MANAGER
-----------------------------------------------------
Name | ZACHARY G RACKOVAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-467-8802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------