Basic Information
| Provider Information | |||||||||
| NPI: | 1669474748 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARC KENTUCKY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DUPONT SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4004 DUPONT CIR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028966428 | ||||||||
| FaxNumber: | 5028935270 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 DUPONT CIR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028966428 | ||||||||
| FaxNumber: | 5028935270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALDOCK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | BOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER AND AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152345935 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 300070 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 36001188 | 05 | KY | MEDICAID |