Healthcare Provider Details

I. General information

NPI: 1528025574
Provider Name (Legal Business Name): KENTUCKY LAKE UROLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 CORNERSTONE DR STE A
PARIS TN
38242
US

IV. Provider business mailing address

1002 CORNERSTONE DR STE A
PARIS TN
38242
US

V. Phone/Fax

Practice location:
  • Phone: 731-642-8884
  • Fax: 731-642-8865
Mailing address:
  • Phone: 731-642-8884
  • Fax: 731-642-8865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LEIGH M HORTON
Title or Position: ASST OFFICE MANAGER
Credential:
Phone: 731-642-8884