Basic Information
| Provider Information | |||||||||
| NPI: | 1215350285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIOSK MEDICINE KENTUCKY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 ELM HILL PIKE | ||||||||
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| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372143108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154254200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 KROGER WAY | ||||||||
| Address2: | |||||||||
| City: | VERSAILLES | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592971072 | ||||||||
| FaxNumber: | 8592971073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2014 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 6154254221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.