Provider Demographics
NPI:1033949854
Name:MADISON COUNTY AESTHETICS
Entity type:Organization
Organization Name:MADISON COUNTY AESTHETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAYLEE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-625-4663
Mailing Address - Street 1:236 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-1628
Mailing Address - Country:US
Mailing Address - Phone:859-582-1087
Mailing Address - Fax:
Practice Address - Street 1:236 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1628
Practice Address - Country:US
Practice Address - Phone:859-582-1087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-06
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100571220Medicaid