Healthcare Provider Details

I. General information

NPI: 1356499602
Provider Name (Legal Business Name): LEXINGTON DIABETIC CENTER PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3292 EAGLE VIEW LN SUITE 210
LEXINGTON KY
40509-2173
US

IV. Provider business mailing address

3292 EAGLE VIEW LN SUITE 210
LEXINGTON KY
40509-2173
US

V. Phone/Fax

Practice location:
  • Phone: 859-977-8855
  • Fax: 859-977-8856
Mailing address:
  • Phone: 859-977-8855
  • Fax: 859-977-8856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number39043
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateKY

VIII. Authorized Official

Name: MICHAEL C. ALLEN
Title or Position: CEO
Credential:
Phone: 859-977-8855