=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922754290
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPASSION PEDIATRICS OF WAYLAND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2022
-----------------------------------------------------
Last Update Date | 05/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2643 KING KELLY COLEMAN HWY
-----------------------------------------------------
City | WAYLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-230-2255
-----------------------------------------------------
Fax | 606-437-3001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 293
-----------------------------------------------------
City | WAYLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41666-0293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-230-2255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LESLEY KYLE BOW
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-456-4591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------