Healthcare Provider Details

I. General information

NPI: 1851338784
Provider Name (Legal Business Name): HURSTBOURNE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 STONY BROOK DR
LOUISVILLE KY
40220-4016
US

IV. Provider business mailing address

2200 STONY BROOK DR
LOUISVILLE KY
40220-4016
US

V. Phone/Fax

Practice location:
  • Phone: 502-495-6240
  • Fax: 502-495-0324
Mailing address:
  • Phone: 502-495-6240
  • Fax: 502-495-0324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100645 PCH
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100645 NF
License Number StateKY

VIII. Authorized Official

Name: ROY T. BABER
Title or Position: MANAGER
Credential:
Phone: 502-495-6240