Provider Demographics
NPI:1306918198
Name:TERRADISE PROPERTIES INC
Entity type:Organization
Organization Name:TERRADISE PROPERTIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:859-238-0002
Mailing Address - Street 1:900 HUSTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 HUSTONVILLE RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2137
Practice Address - Country:US
Practice Address - Phone:859-238-0002
Practice Address - Fax:859-936-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYPO6316332BP3500X, 332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90120114Medicaid
1824754OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY54032826Medicaid
KY54032826Medicaid