18D2127165 CLIA NUMBER - LAKE CUMBERLAND PEDIATRICS, PLLC DBA LAKE CUMBERLAND PRIMARY CARE

Laboratory Demographics

CLIA Number: 18D2127165

Facility Name: LAKE CUMBERLAND PEDIATRICS, PLLC DBA LAKE CUMBERLAND PRIMARY CARE

Facility Address:
268 ROLLING HILLS BLVD
MONTICELLO, KY
ZIP 42633
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Facility Phone Number: 606 753-0293

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1518406859

Taxonomy: 261QR1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	18D2127165
LAB Type	Physician Office
Facility Name	LAKE CUMBERLAND PEDIATRICS, PLLC DBA LAKE CUMBERLAND PRIMARY CARE
Street	268 ROLLING HILLS BLVD
City	MONTICELLO
State	KY
ZIP	42633
Phone	606 753-0293
CertificateType	4
CertificateEffectiveDate	3/10/2023
CertificateExpirationDate	3/9/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024