Basic Information
| Provider Information | |||||||||
| NPI: | 1780950295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PMR KY HOLDING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20801 NW 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331692103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056531770 | ||||||||
| FaxNumber: | 3056530674 | ||||||||
| Practice Location | |||||||||
| Address1: | 8019 DIXIE HWY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402581344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056531770 | ||||||||
| FaxNumber: | 3056500674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 05/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3056531770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101249721 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.