=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356499602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEXINGTON DIABETIC CENTER PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 01/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3292 EAGLE VIEW LN SUITE 210
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-977-8855
-----------------------------------------------------
Fax | 859-977-8856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3292 EAGLE VIEW LN SUITE 210
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-977-8855
-----------------------------------------------------
Fax | 859-977-8856
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL C. ALLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-977-8855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 39043
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------