Provider Demographics
NPI:1326467986
Name:COMMONWEALTH OF KENTUCKY
Entity Type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:LEE SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-564-4527
Mailing Address - Street 1:4501 LOUISE UNDERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-3987
Mailing Address - Country:US
Mailing Address - Phone:502-363-8421
Mailing Address - Fax:
Practice Address - Street 1:4501 LOUISE UNDERWOOD WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-3987
Practice Address - Country:US
Practice Address - Phone:502-363-8421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-10
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty