Healthcare Provider Details

I. General information

NPI: 1972506731
Provider Name (Legal Business Name): COMMONWEALTH OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 STATE AVE
GLASGOW KY
42141-1400
US

IV. Provider business mailing address

207 STATE AVE
GLASGOW KY
42141-1400
US

V. Phone/Fax

Practice location:
  • Phone: 270-659-4700
  • Fax: 270-651-1726
Mailing address:
  • Phone: 270-659-4700
  • Fax: 270-651-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number100483
License Number StateKY

VIII. Authorized Official

Name: MS. AMANDA ALLEN
Title or Position: FACILITY DIRECTOR
Credential:
Phone: 270-659-4707