Healthcare Provider Details

I. General information

NPI: 1558318543
Provider Name (Legal Business Name): LEITCHFIELD PEDIATRIC CLINIC P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 WALLACE AVE
LEITCHFIELD KY
42754-1417
US

IV. Provider business mailing address

901 WALLACE AVE
LEITCHFIELD KY
42754-1417
US

V. Phone/Fax

Practice location:
  • Phone: 270-259-5641
  • Fax: 270-259-5309
Mailing address:
  • Phone: 270-259-5641
  • Fax: 270-259-5309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LYNN ROBINSON
Title or Position: CREDITIALING
Credential:
Phone: 270-259-5641