Basic Information
| Provider Information | |||||||||
| NPI: | 1982746913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUEGRASS FAMILY CHIROPRACTIC, PSC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEALTHSOURCE CHIROPRACTIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1011 PARIS ROAD | ||||||||
| Address2: | #341 | ||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702510907 | ||||||||
| FaxNumber: | 2702510908 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 PARIS ROAD | ||||||||
| Address2: | #341 | ||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702510907 | ||||||||
| FaxNumber: | 2702510908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2702510907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 4764 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 000000289323 | 01 | KY | ANTHEM PIN | OTHER | 85002699 | 05 | KY | MEDICAID |