1114968005 NPI number — TWIN LAKES ANESTHESIOLOGY AND PAIN MANAGEMENT ASSOCIATES

Table of content: (NPI 1114968005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114968005 NPI number — TWIN LAKES ANESTHESIOLOGY AND PAIN MANAGEMENT ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN LAKES ANESTHESIOLOGY AND PAIN MANAGEMENT ASSOCIATES
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:
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:
1114968005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
904 WALLACE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEITCHFIELD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42754-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-259-9470
Provider Business Mailing Address Fax Number:
270-259-1662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 WALLACE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-259-9470
Provider Business Practice Location Address Fax Number:
270-259-1662
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LANGDON
Authorized Official First Name:
JANET
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
270-259-9470

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  TP490 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50011448 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000485100 . This is a "BLUE PREFERRED" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 274629400 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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