Provider Demographics
NPI:1669523684
Name:THE CHILDRENS CLINIC, PLLC.
Entity type:Organization
Organization Name:THE CHILDRENS CLINIC, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:GUCILATAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-699-2210
Mailing Address - Street 1:420 LORETTA ROAD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033
Mailing Address - Country:US
Mailing Address - Phone:270-699-2210
Mailing Address - Fax:270-699-4335
Practice Address - Street 1:420 LORETTA ROAD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033
Practice Address - Country:US
Practice Address - Phone:270-699-2210
Practice Address - Fax:270-699-4335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39507208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty