Healthcare Provider Details

I. General information

NPI: 1710773825
Provider Name (Legal Business Name): DONALD LEE CARR CST/CSFA, KCSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 ALEXANDRIA DR
LEXINGTON KY
40504-3229
US

IV. Provider business mailing address

782 S DOGWOOD DR
BEREA KY
40403-9563
US

V. Phone/Fax

Practice location:
  • Phone: 859-296-3195
  • Fax:
Mailing address:
  • Phone: 859-408-3152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA439
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: