Provider Demographics
NPI:1972617876
Name:LEXINGTON PRIMARY CARE
Entity type:Organization
Organization Name:LEXINGTON PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HATHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-834-1855
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-0249
Mailing Address - Country:US
Mailing Address - Phone:662-834-1855
Mailing Address - Fax:662-834-4953
Practice Address - Street 1:110 TCHULA STREET
Practice Address - Street 2:LEXINGTON PRIMARY CARE
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095
Practice Address - Country:US
Practice Address - Phone:662-834-1855
Practice Address - Fax:662-834-4953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851692261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0115646Medicaid
MS0115646Medicaid