Healthcare Provider Details

I. General information

NPI: 1154341923
Provider Name (Legal Business Name): MASONIC HOMES OF KENTUCKY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MASONIC HOME DR
MASONIC HOME KY
40041-9000
US

IV. Provider business mailing address

240 MASONIC HOME DR
MASONIC HOME KY
40041-9000
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-4907
  • Fax: 502-259-5290
Mailing address:
  • Phone: 502-897-4907
  • Fax: 502-259-5290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number760006
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100225
License Number StateKY

VIII. Authorized Official

Name: MR. TODD L. LACY
Title or Position: CFO
Credential:
Phone: 502-753-8802