Basic Information
| Provider Information | |||||||||
| NPI: | 1447803754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW LEXINGTON CLINIC, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592584000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592584000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2019 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | GAINES | ||||||||
| AuthorizedOfficialFirstName: | DEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASST DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8592586091 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEW LEXINGTON CLINIC, PSC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 0169 | 01 | KY | CMS GROUP | OTHER |