Healthcare Provider Details

I. General information

NPI: 1518787530
Provider Name (Legal Business Name): WILLIAM R MASON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4384 CLEARWATER WAY STE 190
LEXINGTON KY
40515-6493
US

IV. Provider business mailing address

4384 CLEARWATER WAY STE 190
LEXINGTON KY
40515-6493
US

V. Phone/Fax

Practice location:
  • Phone: 859-403-3385
  • Fax:
Mailing address:
  • Phone: 859-403-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: