Healthcare Provider Details

I. General information

NPI: 1033102397
Provider Name (Legal Business Name): KENTUCKY LAKE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 CORNERSTONE DR SUITE B
PARIS TN
38242-5812
US

IV. Provider business mailing address

1002 CORNERSTONE DR SUITE B
PARIS TN
38242-5812
US

V. Phone/Fax

Practice location:
  • Phone: 731-644-2150
  • Fax: 731-644-0474
Mailing address:
  • Phone: 731-644-2150
  • Fax: 731-644-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0000000118
License Number StateTN

VIII. Authorized Official

Name: KAROLYN M MOBLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 731-644-2150