Healthcare Provider Details

I. General information

NPI: 1265681712
Provider Name (Legal Business Name): LEIF CORNELIUS ROBINSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 GOLDEN TIDE AVE APT. 1
CENTRAL CITY KY
42330-1337
US

IV. Provider business mailing address

215 GOLDEN TIDE AVE APT. 1
CENTRAL CITY KY
42330-1337
US

V. Phone/Fax

Practice location:
  • Phone: 270-977-2961
  • Fax:
Mailing address:
  • Phone: 270-977-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberA02405
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: