1053605063 NPI number — PEDIATRIC SPECIALTY CLINIC, LLC.

Table of content: (NPI 1053605063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053605063 NPI number — PEDIATRIC SPECIALTY CLINIC, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC SPECIALTY CLINIC, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053605063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1031 WELLINGTON WAY
Provider Second Line Business Mailing Address:
SUITE 245
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40513-1258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-278-8772
Provider Business Mailing Address Fax Number:
859-303-8852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2647 REGENCY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40503-2959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-276-1088
Provider Business Practice Location Address Fax Number:
859-276-1096
Provider Enumeration Date:
06/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GILES
Authorized Official First Name:
ANN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO/MEMBER
Authorized Official Telephone Number:
859-219-2828

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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