1568528164 NPI number — LAWRENCEBURG CLINIC MEDICINE

Table of content: (NPI 1568528164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568528164 NPI number — LAWRENCEBURG CLINIC MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCEBURG CLINIC MEDICINE
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:
1568528164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 W BROADWAY ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LAWRENCEBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40342-1541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-839-5592
Provider Business Mailing Address Fax Number:
502-839-1041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
504 W BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAWRENCEBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40342-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-839-5592
Provider Business Practice Location Address Fax Number:
502-839-1041
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HINES
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-839-5592

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1174516306 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4500041100 . This is a "EPSDT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65916165 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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