Healthcare Provider Details

I. General information

NPI: 1750317491
Provider Name (Legal Business Name): FLAT LICK MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MARY ALICE DR
FLAT LICK KY
40935-6164
US

IV. Provider business mailing address

PO BOX 346
FLAT LICK KY
40935-0346
US

V. Phone/Fax

Practice location:
  • Phone: 606-542-5900
  • Fax:
Mailing address:
  • Phone: 606-542-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number14797
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TALMADGE V HAYS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 606-542-5900