Healthcare Provider Details

I. General information

NPI: 1689652513
Provider Name (Legal Business Name): COMMONWEALTH OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MEADOWS DR
MT WASHINGTON KY
40047-6013
US

IV. Provider business mailing address

210 MEADOWS DR
MT WASHINGTON KY
40047-6013
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-2301
  • Fax: 502-363-6114
Mailing address:
  • Phone: 502-361-2301
  • Fax: 502-363-6114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number100695
License Number StateKY

VIII. Authorized Official

Name: JENNIFER MOORE
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 502-782-6117