=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679914733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEGRASS FAMILY HEALTHCARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2013
-----------------------------------------------------
Last Update Date | 05/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2337 ELIZABETHTOWN RD
-----------------------------------------------------
City | LEITCHFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42754-9173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-971-1388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2337 ELIZABETHTOWN RD
-----------------------------------------------------
City | LEITCHFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42754-9173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-971-1388
-----------------------------------------------------
Fax | 270-297-7066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RICHARD D BASHAM
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 270-971-1388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 3007397
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------