Provider Demographics
NPI:1588129035
Name:WILD HEALTH AT PROOF LLC
Entity type:Organization
Organization Name:WILD HEALTH AT PROOF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-309-4839
Mailing Address - Street 1:230 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-1340
Mailing Address - Country:US
Mailing Address - Phone:859-309-4839
Mailing Address - Fax:
Practice Address - Street 1:230 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-1340
Practice Address - Country:US
Practice Address - Phone:859-309-4839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty