MEDICARE: TWIN LAKES MEDICAL FOUNDATION INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207V00000X	Obstetrics & Gynecology Physician
2	207X00000X	Orthopaedic Surgery Physician
3	207Y00000X	Otolaryngology Physician
4	207QS0010X	Sports Medicine (Family Medicine) Physician
5	207R00000X	Internal Medicine Physician
6	208000000X	Pediatrics Physician
7	2084N0400X	Neurology Physician
8	208600000X	Surgery Physician
9	207Q00000X	Family Medicine Physician
10	208D00000X	General Practice Physician
11	231H00000X	Audiologist
12	363LA2200X	Adult Health Nurse Practitioner
13	363LF0000X	Family Nurse Practitioner
14	363LP2300X	Primary Care Nurse Practitioner
15	363L00000X	Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
15	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205870862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWIN LAKES MEDICAL FOUNDATION INC

Provider Business Mailing Address
First Line	:	908 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-1479
Country	:	US
Telephone Number	:	270-259-1626
Fax Number	:	270-259-9582

Provider Business Practice Location Address
First Line	:	908 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-1479
Country	:	US
Telephone Number	:	270-259-1626
Fax Number	:	270-259-9582

Authorized Official
Title or Position	:	COO
Name	:	DENEACE CLEMONS
Credential	:
Telephone Number	:	270-259-1626

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	12/09/2019

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