Healthcare Provider Details

I. General information

NPI: 1043766801
Provider Name (Legal Business Name): LETEK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 03/06/2021
Certification Date: 03/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 W MAIN ST UNIT B
MOUNT VERNON KY
40456-2523
US

IV. Provider business mailing address

942 W MAIN ST UNIT B
MOUNT VERNON KY
40456-2523
US

V. Phone/Fax

Practice location:
  • Phone: 731-571-9223
  • Fax: 931-901-1239
Mailing address:
  • Phone: 731-571-9223
  • Fax: 931-901-1239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38140
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number38140
License Number StateKY

VIII. Authorized Official

Name: DR. THOMAS WILLIAM FOWLES
Title or Position: OWNER
Credential: M.D.
Phone: 859-358-3069