Healthcare Provider Details

I. General information

NPI: 1114926854
Provider Name (Legal Business Name): GRAYSON COUNTY HOSPITAL FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 WALLACE AVE
LEITCHFIELD KY
42754-1418
US

IV. Provider business mailing address

910 WALLACE AVE
LEITCHFIELD KY
42754-1418
US

V. Phone/Fax

Practice location:
  • Phone: 270-259-9525
  • Fax: 270-259-1670
Mailing address:
  • Phone: 270-259-9525
  • Fax: 270-259-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number150102
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number150102
License Number StateKY

VIII. Authorized Official

Name: MRS. MONA GAIL FULKERSON
Title or Position: DIRECTOR OF HOME HEALTH
Credential: RN
Phone: 270-259-9525