Provider Demographics
NPI:1407006760
Name:KENTUCKY INTERVENTIONAL SPINE
Entity type:Organization
Organization Name:KENTUCKY INTERVENTIONAL SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:859-238-7746
Mailing Address - Street 1:236 W MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1876
Mailing Address - Country:US
Mailing Address - Phone:859-238-7746
Mailing Address - Fax:
Practice Address - Street 1:236 W MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1876
Practice Address - Country:US
Practice Address - Phone:859-238-7746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP2362081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty