Basic Information
| Provider Information | |||||||||
| NPI: | 1508955832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEXINGTON CLINIC CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LEXINGTON FAMILY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383512038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319683646 | ||||||||
| FaxNumber: | 7319683646 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383512013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319684477 | ||||||||
| FaxNumber: | 7319671202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENSON | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RCD | ||||||||
| AuthorizedOfficialTelephone: | 3369446420 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEXINGTON CLINIC CORP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0443962 | 05 | TN | MEDICAID | 1513805 | 05 | TN | MEDICAID |