1902403264 NPI number — PROFESSIONAL PARK DIAGNOSTICS PLLC

Table of content: (NPI 1902403264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902403264 NPI number — PROFESSIONAL PARK DIAGNOSTICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PARK DIAGNOSTICS PLLC
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:
1902403264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3346 PROFESSIONAL PARK
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42303-4551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-852-8931
Provider Business Mailing Address Fax Number:
270-852-8924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3346 PROFESSIONAL PARK
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42303-4551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-228-0405
Provider Business Practice Location Address Fax Number:
270-852-8924
Provider Enumeration Date:
10/08/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MATTINGLY
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
270-852-8931

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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