Basic Information
Provider Information | |||||||||
NPI: | 1023426632 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MED-LIFE-FIT MEDICAL AND LIFESTYLE MANAGEMENT FAMILY MEDICAL CENTER L | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KENTUCKIANA MEDICAL WEIGHT LOSS CENTERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10512 MEETING ST STE 101 | ||||||||
Address2: |   | ||||||||
City: | PROSPECT | ||||||||
State: | KY | ||||||||
PostalCode: | 400597590 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022764706 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10512 MEETING ST STE 101 | ||||||||
Address2: |   | ||||||||
City: | PROSPECT | ||||||||
State: | KY | ||||||||
PostalCode: | 400597590 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022764706 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2014 | ||||||||
LastUpdateDate: | 06/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HORN | ||||||||
AuthorizedOfficialFirstName: | LINDSAY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5023719700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QB0002X | 34201 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine | 363LP2300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 207Q00000X | 34201 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.