=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588389126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KY CARES TESTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2022
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 HAPPY VALLEY RD
-----------------------------------------------------
City | GLASGOW
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42141-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-651-5159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 HAPPY VALLEY RD
-----------------------------------------------------
City | GLASGOW
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42141-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-651-5159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TRAVIS HUDNALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-651-5159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------