Provider Demographics
NPI:1871871780
Name:GREATER KENTUCKY WELLNESS CENTER LLC
Entity type:Organization
Organization Name:GREATER KENTUCKY WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-717-1018
Mailing Address - Street 1:101 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1117
Mailing Address - Country:US
Mailing Address - Phone:606-717-1018
Mailing Address - Fax:
Practice Address - Street 1:101 RIVER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1117
Practice Address - Country:US
Practice Address - Phone:606-717-1018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain