Healthcare Provider Details

I. General information

NPI: 1235343419
Provider Name (Legal Business Name): PIKEVILLE DERMATOLOGY & COSMETIC CENTER, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N AUXIER AVE
PIKEVILLE KY
41501-9045
US

IV. Provider business mailing address

108 N AUXIER AVE
PIKEVILLE KY
41501-9045
US

V. Phone/Fax

Practice location:
  • Phone: 606-432-9106
  • Fax: 606-432-0967
Mailing address:
  • Phone: 606-432-9106
  • Fax: 606-432-0967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number02627
License Number StateKY

VIII. Authorized Official

Name: DR. TIMOTHY R LAVENDER
Title or Position: OWNER & PHYSICIAN
Credential: D.O.
Phone: 606-432-9106