Provider Demographics
NPI:1861796302
Name:BLUEGRASS AUDIOLOGY, LLC
Entity type:Organization
Organization Name:BLUEGRASS AUDIOLOGY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST, HEARING INSTRUMENT SPE
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-A
Authorized Official - Phone:904-445-1622
Mailing Address - Street 1:8550 TOUCHTON RD APT 2236
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2237
Mailing Address - Country:US
Mailing Address - Phone:904-445-1622
Mailing Address - Fax:904-293-1815
Practice Address - Street 1:100 JOHN SUTHERLAND DR
Practice Address - Street 2:SUITE 4
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-2424
Practice Address - Country:US
Practice Address - Phone:859-885-0150
Practice Address - Fax:859-885-0175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-24
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0814237700000X
KYKY-0419231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty