Basic Information
| Provider Information | |||||||||
| NPI: | 1285930834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL KENTUCKY MOBILITY OF BOWLING GREEN, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1050 ENTERPRISE DR | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405101016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592253624 | ||||||||
| FaxNumber: | 8592253682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1017 SHIVE LN | ||||||||
| Address2: | SUITE E | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421038039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709044934 | ||||||||
| FaxNumber: | 2709042658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRESTON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8592253624 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | KY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | KY | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
No ID Information.