Basic Information
| Provider Information | |||||||||
| NPI: | 1326331083 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 PAULINE DR | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404038889 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 PAULINE DR | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404038889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592334511 | ||||||||
| FaxNumber: | 8599861289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2011 | ||||||||
| LastUpdateDate: | 05/27/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREGORY | ||||||||
| AuthorizedOfficialFirstName: | LYDIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | STAFF NURSE | ||||||||
| AuthorizedOfficialTelephone: | 8592334511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 1096474 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.