Healthcare Provider Details

I. General information

NPI: 1023426632
Provider Name (Legal Business Name): MED-LIFE-FIT MEDICAL AND LIFESTYLE MANAGEMENT FAMILY MEDICAL CENTER L
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2014
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10512 MEETING ST STE 101
PROSPECT KY
40059-7590
US

IV. Provider business mailing address

10512 MEETING ST STE 101
PROSPECT KY
40059-7590
US

V. Phone/Fax

Practice location:
  • Phone: 502-276-4706
  • Fax:
Mailing address:
  • Phone: 502-276-4706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34201
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number34201
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LINDSAY HORN
Title or Position: OFFICE MANAGER
Credential:
Phone: 502-371-9700