| Organization Name: | PINELAKE PHYSICIAN PRACTICE LLC |
| NPI Number: | 1255650479 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TIMOTHY D VAUGHN (VICE PRESIDENT) |
| Mailing Address: | 1111 Medical Center Cir Mayfield |
| State: | KY US |
| Postal Code: | 420661194 |
| Phone Number: | 2702514080 |
| Fax Number: | 2702514081 |
| NPI Enumeration Date: | 05/27/2010 |
| NPI Last Update Date: | 05/27/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 207YX0905X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Otolaryngology |
| Taxonomy Specialization: | Otolaryngology/Facial Plastic Surgery |
| Taxonomy Definition: | An otolaryngologist who specializes in the diagnosis and surgical treatment of head and neck conditions. |