Healthcare Provider Details

I. General information

NPI: 1053605063
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY CLINIC, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 REGENCY RD
LEXINGTON KY
40503-2959
US

IV. Provider business mailing address

1031 WELLINGTON WAY SUITE 245
LEXINGTON KY
40513-1258
US

V. Phone/Fax

Practice location:
  • Phone: 859-276-1088
  • Fax: 859-276-1096
Mailing address:
  • Phone: 859-278-8772
  • Fax: 859-303-8852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. ANN S GILES
Title or Position: CEO/MEMBER
Credential:
Phone: 859-219-2828