| Organization Name: | KENTUCKY MEDICAL SPA |
| NPI Number: | 1326440637 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JERRY BRACKETT (PRESIDENT) |
| Mailing Address: | 636 Jefferson Ave Paintsville |
| State: | KY US |
| Postal Code: | 412401349 |
| Phone Number: | 6067881035 |
| Fax Number: | 6067881045 |
| NPI Enumeration Date: | 09/17/2014 |
| NPI Last Update Date: | 09/17/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 14390 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |