Provider Demographics
NPI:1033102397
Name:KENTUCKY LAKE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:KENTUCKY LAKE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAROLYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-644-2150
Mailing Address - Street 1:1002 CORNERSTONE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-5812
Mailing Address - Country:US
Mailing Address - Phone:731-644-2150
Mailing Address - Fax:731-644-0474
Practice Address - Street 1:1002 CORNERSTONE DR
Practice Address - Street 2:SUITE B
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-5812
Practice Address - Country:US
Practice Address - Phone:731-644-2150
Practice Address - Fax:731-644-0474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000118261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3288139Medicaid
TN490004547OtherPALMETO GBA PROVIDER NUMB
TN3144925OtherBLUE CROSS PROVIDER NUMBE
TN3288139Medicaid