Healthcare Provider Details

I. General information

NPI: 1922643287
Provider Name (Legal Business Name): KENTUCKY CUSTOM CARE PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 PATTON RD
BOSTON KY
40107-8700
US

IV. Provider business mailing address

3200 PATTON RD
BOSTON KY
40107-8700
US

V. Phone/Fax

Practice location:
  • Phone: 502-331-1085
  • Fax:
Mailing address:
  • Phone: 502-331-1085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY FENWICK
Title or Position: OWNER
Credential: CPA
Phone: 502-331-1085