Healthcare Provider Details

I. General information

NPI: 1033613542
Provider Name (Legal Business Name): ANNVILLE-KY ADULT DAYCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 HIGHWAY 3444
ANNVILLE KY
40402-8245
US

IV. Provider business mailing address

78 HIGHWAY 3444
ANNVILLE KY
40402-8245
US

V. Phone/Fax

Practice location:
  • Phone: 606-346-5162
  • Fax: 606-364-3920
Mailing address:
  • Phone: 606-346-5162
  • Fax: 606-364-3920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARLA J JOHNSON
Title or Position: CREDENTIALING/BILLING MANAGER
Credential:
Phone: 606-843-6195