Healthcare Provider Details

I. General information

NPI: 1376738922
Provider Name (Legal Business Name): OWENSBORO HABILITATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 FREDERICA ST
OWENSBORO KY
42301-4807
US

IV. Provider business mailing address

1620 FREDERICA ST
OWENSBORO KY
42301-4807
US

V. Phone/Fax

Practice location:
  • Phone: 270-302-6538
  • Fax:
Mailing address:
  • Phone: 270-302-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN R PARKER
Title or Position: BUSINESS OFFICE MANAGER
Credential: MBA
Phone: 270-302-6538