Provider Demographics
NPI:1619395605
Name:WESTERN KY MEDICAL, LLC
Entity type:Organization
Organization Name:WESTERN KY MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR PRACTICE MGMT
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-533-8762
Mailing Address - Street 1:1317 ROUTE 73 STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2202
Mailing Address - Country:US
Mailing Address - Phone:856-439-6111
Mailing Address - Fax:
Practice Address - Street 1:609 HAMMOND PLZ
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4971
Practice Address - Country:US
Practice Address - Phone:270-887-8333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINNACLE TREATMENT CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-07
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY810381261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY810381OtherSTATE LICNESE