Healthcare Provider Details

I. General information

NPI: 1144270018
Provider Name (Legal Business Name): PAIGE PRIMARY CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 NEW MOODY LN SUITE 201
LA GRANGE KY
40031-9177
US

IV. Provider business mailing address

1023 NEW MOODY LN SUITE 201
LA GRANGE KY
40031-9177
US

V. Phone/Fax

Practice location:
  • Phone: 502-225-4480
  • Fax: 502-225-9169
Mailing address:
  • Phone: 502-225-4480
  • Fax: 502-225-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41864
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. CARLTON DAMON PAIGE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 502-225-4480