Healthcare Provider Details

I. General information

NPI: 1053689018
Provider Name (Legal Business Name): MILL POND FAMILY CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 BOSTON RD SUITE E
LEXINGTON KY
40514-1569
US

IV. Provider business mailing address

3051 KIRKLEVINGTON DR 173
LEXINGTON KY
40517-2422
US

V. Phone/Fax

Practice location:
  • Phone: 859-219-0617
  • Fax:
Mailing address:
  • Phone: 925-487-0253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5298
License Number StateKY

VIII. Authorized Official

Name: DR. JUSTIN PEARCE
Title or Position: OWNER
Credential: D.C.
Phone: 859-219-0617