Provider Demographics
NPI:1679262737
Name:KDPCTN
Entity type:Organization
Organization Name:KDPCTN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TANYIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-701-0213
Mailing Address - Street 1:9200 SHELBYVILLE RD STE 531
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 CENTRAL PIKE STE 500
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3419
Practice Address - Country:US
Practice Address - Phone:502-792-0236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty