Organization
KENTUCKY LAKE SURGERY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KAROLYN M MOBLEY (ADMINISTRATOR)
(731) 644-2150
Entity
Organization
Contact information
Practice address
1002 CORNERSTONE DR, SUITE B, PARIS, TN 38242-5812
(731) 644-2150
(731) 644-0474
Mailing address
1002 CORNERSTONE DR, SUITE B, PARIS, TN 38242-5812
(731) 644-2150
(731) 644-0474
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
0000000118
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3144925
BLUE CROSS PROVIDER NUMBE
TN
05
—
3288139
—
TN
01
—
490004547
PALMETO GBA PROVIDER NUMB
TN
Enumeration date
08/23/2005
Last updated
01/28/2011
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