=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548597016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN KENTUCKY CENTER FOR PAIN RELIEF, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2009
-----------------------------------------------------
Last Update Date | 02/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8780 US HIGHWAY 42
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41042-6936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-292-0123
-----------------------------------------------------
Fax | 859-292-0131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8780 US HWY 42 SUITE A
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-292-0123
-----------------------------------------------------
Fax | 859-292-0131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | VICKI SEBASTIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-292-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------