Provider Demographics
NPI:1194929943
Name:KENTUCKY LAPAROSCOPIC & ADVANCED SURGICAL SPECIALISTS, PLLC
Entity type:Organization
Organization Name:KENTUCKY LAPAROSCOPIC & ADVANCED SURGICAL SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-886-8240
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-5239
Mailing Address - Country:US
Mailing Address - Phone:606-886-8240
Mailing Address - Fax:606-886-8243
Practice Address - Street 1:5322 KY ROUTE 321
Practice Address - Street 2:SUITE 1
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9114
Practice Address - Country:US
Practice Address - Phone:606-886-8240
Practice Address - Fax:606-886-8243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02979208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty