=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538910948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN KENTUCKY TREATMENT CENTER OF LEXINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2024
-----------------------------------------------------
Last Update Date | 04/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 851 N BROADWAY
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-1474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-661-0121
-----------------------------------------------------
Fax | 859-488-7448
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 851 N BROADWAY
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-1474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-661-0121
-----------------------------------------------------
Fax | 859-488-7448
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM MORGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-661-0121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------