Provider Demographics
NPI:1053319376
Name:STEVIE TROSPER
Entity type:Organization
Organization Name:STEVIE TROSPER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:TROSPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-248-9020
Mailing Address - Street 1:1930 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1231
Mailing Address - Country:US
Mailing Address - Phone:606-248-9020
Mailing Address - Fax:606-248-9015
Practice Address - Street 1:1930 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1231
Practice Address - Country:US
Practice Address - Phone:606-248-9020
Practice Address - Fax:606-248-9015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY258490332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90007089Medicaid
KY90007089Medicaid