Healthcare Provider Details

I. General information

NPI: 1467683730
Provider Name (Legal Business Name): SHADY LAWN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 SOUTH MILLER STREET
CYNTHIANAN KY
41031
US

IV. Provider business mailing address

108 SOUTH MILLER STREET
CYNTHIANA KY
41031
US

V. Phone/Fax

Practice location:
  • Phone: 859-234-2606
  • Fax: 859-234-6684
Mailing address:
  • Phone: 859-234-2606
  • Fax: 859-234-6684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number100170
License Number StateKY

VIII. Authorized Official

Name: MRS. KELLI LYNN BAILEY
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 859-234-2606