Basic Information
Provider Information | |||||||||
NPI: | 1669711487 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEW VISTA OF THE BLUEGRASS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BLUEGRASS.ORG | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1351 NEWTOWN PIKE | ||||||||
Address2: | BLDG 5 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405111275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592531686 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1351 NEWTOWN PIKE | ||||||||
Address2: | BLDG 5 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405111275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592531686 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2013 | ||||||||
LastUpdateDate: | 10/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WERLINE | ||||||||
AuthorizedOfficialFirstName: | DEE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 8592531686 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 33900119 | 05 | KY |   | MEDICAID | 874068 | 01 |   | USA | OTHER | 20354400 | 01 |   | MEGELLAN | OTHER | 207023 | 01 | KY | MHN | OTHER | 270151015 | 05 | KY |   | MEDICAID | 000000057414 | 01 | KY | ATHEM | OTHER | 091018 | 01 | KY | VALUE OPTIONS | OTHER | 29000003 | 05 | KY |   | MEDICAID | 1790731081 | 05 | KY |   | MEDICAID | 242395 | 01 | KY | COMPSYCH | OTHER | 101483 | 01 | KY | CHA INSURANCE | OTHER | 28015014 | 05 | KY |   | MEDICAID |