Healthcare Provider Details

I. General information

NPI: 1194741017
Provider Name (Legal Business Name): LEXINGTON PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 WELLINGTON WAY SUITE 215
LEXINGTON KY
40513-1259
US

IV. Provider business mailing address

1055 WELLINGTON WAY SUITE 275
LEXINGTON KY
40513-1259
US

V. Phone/Fax

Practice location:
  • Phone: 859-422-4369
  • Fax: 859-422-4359
Mailing address:
  • Phone: 859-219-2828
  • Fax: 859-219-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18482
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANN S GILES
Title or Position: ADMINISTRATOR OWNER
Credential:
Phone: 859-219-2828