MEDICARE: DAIQUIRI FALLON AMS LPCC-S

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	171234	KY

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

General Provider Information

NPI Number	:	1427471549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAIQUIRI FALLON AMS LPCC-S

Provider Business Mailing Address
First Line	:	4537 LARGO LN
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40515-5124
Country	:	US
Telephone Number	:	859-279-2031
Fax Number	:

Provider Business Practice Location Address
First Line	:	4537 LARGO LN
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40515-5124
Country	:	US
Telephone Number	:	859-279-2031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2014
Last Update Date	:	06/05/2026

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