Healthcare Provider Details

I. General information

NPI: 1669542825
Provider Name (Legal Business Name): BREATITT COUNTY GERIATRIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 JETT DR
JACKSON KY
41339-9621
US

IV. Provider business mailing address

420 JETT DR
JACKSON KY
41339-9621
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-2456
  • Fax: 606-666-9376
Mailing address:
  • Phone: 606-666-2456
  • Fax: 606-666-9376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberKY100040
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberKY100040
License Number StateKY

VIII. Authorized Official

Name: MR. PHILLIP LITTERAL
Title or Position: ADMINISTRATOR
Credential:
Phone: 606-666-2456