Basic Information
Provider Information | |||||||||
NPI: | 1366079543 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KING'S DAUGHTERS MEDICAL SPECIALTIES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KINGS DAUGHTERS FOOT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2379 | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 411052379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064086200 | ||||||||
FaxNumber: | 6064086612 | ||||||||
Practice Location | |||||||||
Address1: | 1000 ASHLAND DR STE 104 | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 411017092 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6068336260 | ||||||||
FaxNumber: | 6068336261 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2020 | ||||||||
LastUpdateDate: | 06/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITLATCH | ||||||||
AuthorizedOfficialFirstName: | KRISTIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6064084401 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
No ID Information.