Provider Demographics
NPI:1669519112
Name:LK MANSFIELD LLC
Entity type:Organization
Organization Name:LK MANSFIELD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-265-2155
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:KY
Mailing Address - Zip Code:42220-0460
Mailing Address - Country:US
Mailing Address - Phone:270-265-2155
Mailing Address - Fax:270-265-2460
Practice Address - Street 1:44 PUBLIC SQUARE
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:KY
Practice Address - Zip Code:42220
Practice Address - Country:US
Practice Address - Phone:270-265-2155
Practice Address - Fax:270-265-2460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP080113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100611690Medicaid
KY7100549770Medicaid
KY54034848Medicaid