Healthcare Provider Details

I. General information

NPI: 1427583178
Provider Name (Legal Business Name): COMMONWEALTH MEDICAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 GOVERNORS LN SUITE 220
LEXINGTON KY
40513-1173
US

IV. Provider business mailing address

989 GOVERNORS LN SUITE 240
LEXINGTON KY
40513-1173
US

V. Phone/Fax

Practice location:
  • Phone: 859-338-3958
  • Fax: 859-368-8135
Mailing address:
  • Phone: 859-338-3958
  • Fax: 859-368-8135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MATT BEAVIN
Title or Position: OWNER
Credential:
Phone: 859-338-3958