=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639340912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEGRASS CHIROPRACTIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2008
-----------------------------------------------------
Last Update Date | 07/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1132 WINCHESTER RD STE 125
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40505-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-254-0059
-----------------------------------------------------
Fax | 859-254-1033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1132 WINCHESTER ROAD SUITE 125
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-254-0059
-----------------------------------------------------
Fax | 859-254-1033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BARRY LEON PELTON
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 859-254-0059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3973
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------