| Organization Name: | KENTUCKY LAKE SURGERY CENTER LLC |
| NPI Number: | 1033102397 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KAROLYN M MOBLEY (ADMINISTRATOR) |
| Mailing Address: | 1002 Cornerstone Dr Suite B Paris |
| State: | TN US |
| Postal Code: | 382425812 |
| Phone Number: | 7316442150 |
| Fax Number: | 7316440474 |
| NPI Enumeration Date: | 08/23/2005 |
| NPI Last Update Date: | 01/28/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QA1903X |
| License Number: | 0000000118 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TN |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Ambulatory Surgical |
| Taxonomy Definition: | |