Basic Information
| Provider Information | |||||||||
| NPI: | 1265851760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMONWEALTH OF KENTUCKY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OUTWOOD SPECIALTY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23524 DAWSON SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | DAWSON SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424089205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707973771 | ||||||||
| FaxNumber: | 2707973592 | ||||||||
| Practice Location | |||||||||
| Address1: | 23524 DAWSON SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | DAWSON SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424089205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707973771 | ||||||||
| FaxNumber: | 2707973592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2014 | ||||||||
| LastUpdateDate: | 04/11/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORRIS | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY COMMISSIONER | ||||||||
| AuthorizedOfficialTelephone: | 5025644527 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMONWEALTH OF KENTUCKY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.