Healthcare Provider Details

I. General information

NPI: 1578552352
Provider Name (Legal Business Name): NEW JACKSON MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 STATE ROAD 3444
ANNVILLE KY
40402-8701
US

IV. Provider business mailing address

PO BOX 194
ANNVILLE KY
40402-0194
US

V. Phone/Fax

Practice location:
  • Phone: 606-364-5197
  • Fax: 606-364-2293
Mailing address:
  • Phone: 606-364-5197
  • Fax: 606-364-2293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100602
License Number StateKY

VIII. Authorized Official

Name: MR. PHILIP GILKISON
Title or Position: ADMINISTRATOR
Credential:
Phone: 606-364-5197