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General NPI Number Information
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NPI Number | 1669523684
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Entity Type | Organization
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Legal Business Name | THE CHILDRENS CLINIC, PLLC.
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 420 LORETTA ROAD
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City | LEBANON
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State | KY
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Zip | 40033
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Country | US
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Telephone | 270-699-2210
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Fax | 270-699-4335
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Provider Business Mailing Address
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Address Line | 420 LORETTA ROAD
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City | LEBANON
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State | KY
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Zip | 40033
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Country | US
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Telephone | 270-699-2210
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Fax | 270-699-4335
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Authorized Official
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Title or Position | OWNER
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Name | MAX GUCILATAR
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Credential | M.D.
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Telephone | 270-699-2210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 39507
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License Number State | KY
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