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General NPI Number Information
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NPI Number | 1649681099
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Entity Type | Organization
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Legal Business Name | NKY MED, LLC
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Dates
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Enumeration Date | 05/19/2014
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Last Update Date | 12/20/2019
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Provider Practice Location Address
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Address Line | 1717 MADISON AVE
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City | COVINGTON
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State | KY
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Zip | 41011-3330
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Country | US
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Telephone | 859-360-0250
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Fax |
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Provider Business Mailing Address
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Address Line | 1317 ROUTE 73 STE 200
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City | MOUNT LAUREL
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State | NJ
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Zip | 08054-2202
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Country | US
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Telephone | 856-439-6111
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Fax | 856-780-5153
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR OF CONTRACT MGMT
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Name | ROBYN TANIS
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Credential |
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Telephone | 856-533-8762
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number | 810355
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License Number State | KY
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