Provider Demographics
NPI:1578032926
Name:DOCTOR'S HEALTH & WEIGHTLOSS CLINIC
Entity Type:Organization
Organization Name:DOCTOR'S HEALTH & WEIGHTLOSS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:B
Authorized Official - Last Name:PEDDICORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-387-0323
Mailing Address - Street 1:102 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:KY
Mailing Address - Zip Code:42602-1302
Mailing Address - Country:US
Mailing Address - Phone:606-387-2025
Mailing Address - Fax:606-387-9665
Practice Address - Street 1:102 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-1302
Practice Address - Country:US
Practice Address - Phone:606-387-2025
Practice Address - Fax:606-387-9665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100585770Medicaid