Basic Information
| Provider Information | |||||||||
| NPI: | 1003562810 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMAC MEDICAL OF KENTUCKY PSC | ||||||||
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| OtherOrganizationName: | IMAC MEDICAL OF KENTUCKY PSC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 WESTGATE CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370278396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156780024 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2537 LARKIN RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405033201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595450043 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2022 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOYETT | ||||||||
| AuthorizedOfficialFirstName: | BAILEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6156780024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 163WP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Pain Management |
No ID Information.