=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942027891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAST PACE KENTUCKY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2024
-----------------------------------------------------
Last Update Date | 09/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1635 COLLEGE AVE
-----------------------------------------------------
City | SPINDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-330-9190
-----------------------------------------------------
Fax | 828-330-9191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 681029
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37068-1029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-253-1110
-----------------------------------------------------
Fax | 931-722-9919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CREDENTIALING
-----------------------------------------------------
Name | MELISSA HARLAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-948-9639
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------