Provider Demographics
NPI:1528025574
Name:KENTUCKY LAKE UROLOGY CLINIC
Entity Type:Organization
Organization Name:KENTUCKY LAKE UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:M
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-642-8884
Mailing Address - Street 1:1002 CORNERSTONE DR
Mailing Address - Street 2:STE A
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242
Mailing Address - Country:US
Mailing Address - Phone:731-642-8884
Mailing Address - Fax:731-642-8865
Practice Address - Street 1:1002 CORNERSTONE DR
Practice Address - Street 2:STE A
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242
Practice Address - Country:US
Practice Address - Phone:731-642-8884
Practice Address - Fax:731-642-8865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCM3751OtherRAILROAD MEDICARE
TN3701995Medicaid
TN3701995Medicaid