Basic Information
Provider Information | |||||||||
NPI: | 1609462472 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRIGHTVIEW LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 615 ELSINORE PL STE 200 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452021459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138347063 | ||||||||
FaxNumber: | 5138731567 | ||||||||
Practice Location | |||||||||
Address1: | 506 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | NICHOLASVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 403561134 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138347063 | ||||||||
FaxNumber: | 5138731567 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2020 | ||||||||
LastUpdateDate: | 02/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOVALL | ||||||||
AuthorizedOfficialFirstName: | ANDREA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 5138347063 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BRIGHTVIEW LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 207RA0401X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 7100715180 | 05 | KY |   | MEDICAID |