Organization
SOUTHGATE MEDICAL OF KY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RALPH L STACEY II (OWNER ADMINISTRATOR)
(859) 292-8880
Entity
Organization
Contact information
Practice address
425 GARRARD ST, COVINGTON, KY 41011-2562
(859) 292-8880
(859) 292-8923
Mailing address
425 GARRARD ST, COVINGTON, KY 41011-2562
(859) 292-8880
(859) 292-8923
Taxonomy
Speciality
Code
Description
License number
State
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9047059200
—
KY
Enumeration date
02/07/2007
Last updated
08/22/2020
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