1578891057 NPI number — MINUTECLINIC DIAGNOSTIC OF KENTUCKY LLC

Table of content: (NPI 1578891057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578891057 NPI number — MINUTECLINIC DIAGNOSTIC OF KENTUCKY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINUTECLINIC DIAGNOSTIC OF KENTUCKY 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:
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:
1578891057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 772
Provider Second Line Business Mailing Address:
CREDENTIALING-MC2295
Provider Business Mailing Address City Name:
WOONSOCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02895-0784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-389-2727
Provider Business Mailing Address Fax Number:
401-406-3539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2311 LIME KILN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40222-3460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-389-2727
Provider Business Practice Location Address Fax Number:
401-406-3539
Provider Enumeration Date:
11/23/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PINCINCE
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
401-770-3813

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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