Healthcare Provider Details

I. General information

NPI: 1992818009
Provider Name (Legal Business Name): PEDORTHIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 SOUTHLAND DR
LEXINGTON KY
40503-1824
US

IV. Provider business mailing address

371 SOUTHLAND DR
LEXINGTON KY
40503-1824
US

V. Phone/Fax

Practice location:
  • Phone: 859-266-0420
  • Fax: 859-266-0667
Mailing address:
  • Phone: 859-266-0420
  • Fax: 859-266-0667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY WHEELER
Title or Position: OWNER
Credential: C.PED
Phone: 859-266-0420