Basic Information
| Provider Information | |||||||||
| NPI: | 1740681543 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY BUSINESS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | RENEWED YOU CLINIC LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 225 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | STANTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403803014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066630333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | STANTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403803014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066630333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2014 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPERRY | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6066630333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 740305 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.