Healthcare Provider Details

I. General information

NPI: 1295960532
Provider Name (Legal Business Name): PINELAKE PHYSICIAN PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER CIR
MAYFIELD KY
42066-1194
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY ATTEN: PROVIDER ENROLLMENT
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-4543
  • Fax: 270-251-4544
Mailing address:
  • Phone: 615-920-7192
  • Fax: 615-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHARLOTTE LAWRENCE
Title or Position: SECRETARY
Credential:
Phone: 615-920-7688