Healthcare Provider Details

I. General information

NPI: 1336435403
Provider Name (Legal Business Name): HEALTHSURE MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 GREATSTONE PT
LEXINGTON KY
40504-3274
US

IV. Provider business mailing address

2406 GREATSTONE POINT
LEXINGTON KY
40504-3274
US

V. Phone/Fax

Practice location:
  • Phone: 859-223-0006
  • Fax: 859-224-0005
Mailing address:
  • Phone: 859-223-0006
  • Fax: 859-224-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number02871
License Number StateKY

VIII. Authorized Official

Name: DR. PEACE N JESSA
Title or Position: OWNER
Credential: DO
Phone: 859-223-0006