Basic Information
| Provider Information | |||||||||
| NPI: | 1780652107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEXINGTON CLINIC CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383512038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319683646 | ||||||||
| FaxNumber: | 7319681705 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383512038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319683646 | ||||||||
| FaxNumber: | 7319671202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | HENSON | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCD | ||||||||
| AuthorizedOfficialTelephone: | 3369446420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3732906 | 05 | TN | MEDICAID |