Healthcare Provider Details

I. General information

NPI: 1659673655
Provider Name (Legal Business Name): MODERN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 NANCY COX DR SUITE D
CAMPBELLSVILLE KY
42718-6834
US

IV. Provider business mailing address

104 NANCY COX DR SUITE D
CAMPBELLSVILLE KY
42718-6834
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-8508
  • Fax: 270-465-8504
Mailing address:
  • Phone: 270-465-8508
  • Fax: 270-465-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateKY

VIII. Authorized Official

Name: MS. TRINA R SANDUSKY
Title or Position: MEMBER
Credential: RN
Phone: 502-523-8044