Healthcare Provider Details

I. General information

NPI: 1811430978
Provider Name (Legal Business Name): PENTECOSTAL CHILDREN'S HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 KY 3439
BARBOURVILLE KY
40906-7201
US

IV. Provider business mailing address

PO BOX 550
BARBOURVILLE KY
40906-0550
US

V. Phone/Fax

Practice location:
  • Phone: 606-546-3805
  • Fax: 606-546-3903
Mailing address:
  • Phone: 606-546-3805
  • Fax: 606-546-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number810530
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number800232
License Number StateKY

VIII. Authorized Official

Name: MISS HOLLY R TAYLOR
Title or Position: TREATMENT DIRECTOR
Credential: LPCC
Phone: 606-546-3805