Healthcare Provider Details

I. General information

NPI: 1801909304
Provider Name (Legal Business Name): KLONDIKE MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 KLONDIKE LANE
LOUISVILLE KY
40218-1796
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 502-452-1579
  • Fax: 502-451-9310
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100424
License Number StateKY

VIII. Authorized Official

Name: WILLIAM MATHIES
Title or Position: PRESIDENT DIRECTOR
Credential:
Phone: 505-821-3355