Provider Demographics
NPI:1215207444
Name:MEDINA, CARMEN ALEXANDRA (DC)
Entity Type:Individual
Prefix:MISS
First Name:CARMEN
Middle Name:ALEXANDRA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S L ROGERS WELLS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1043
Mailing Address - Country:US
Mailing Address - Phone:270-834-8922
Mailing Address - Fax:270-834-1730
Practice Address - Street 1:507 S L ROGERS WELLS BLVD
Practice Address - Street 2:STE A
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1043
Practice Address - Country:US
Practice Address - Phone:270-834-8922
Practice Address - Fax:270-834-1730
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor