Provider Demographics
NPI:1861993263
Name:HEALTHCARE FOR KIDS & TEENS, PLLC
Entity type:Organization
Organization Name:HEALTHCARE FOR KIDS & TEENS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-692-9015
Mailing Address - Street 1:54 MILLER PIKE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-9248
Mailing Address - Country:US
Mailing Address - Phone:270-692-9015
Mailing Address - Fax:270-692-9008
Practice Address - Street 1:54 MILLER PIKE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-9248
Practice Address - Country:US
Practice Address - Phone:270-692-9015
Practice Address - Fax:270-692-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004368208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1942307079OtherPROVIDER NPI
KY3004368OtherAPRN LICENSE
KY78013729Medicaid