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General NPI Number Information
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NPI Number | 1154084887
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Entity Type | Individual
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Provider Name | JOHN CLARK LAWRENCE C.PED
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Gender | Male
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Dates
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Enumeration Date | 10/19/2021
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 77 MACK WALTERS RD STE 301B
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City | SHELBYVILLE
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State | KY
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Zip | 40065-1793
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Country | US
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Telephone | 502-437-0134
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Fax |
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Provider Business Mailing Address
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Address Line | 1705 MANLEY LEESTOWN RD
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City | FRANKFORT
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State | KY
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Zip | 40601-9494
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Country | US
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Telephone | 502-803-5570
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224L00000X
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Taxonomy Name | Pedorthist
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License Number | 4669
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License Number State | KY
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