Healthcare Provider Details

I. General information

NPI: 1346890878
Provider Name (Legal Business Name): RUSSELLVILLE KY OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 BOYLES DR
RUSSELLVILLE KY
42276-8838
US

IV. Provider business mailing address

2100 CHEROKEE RIDGE WAY STE 100
LOUISVILLE KY
40205-1600
US

V. Phone/Fax

Practice location:
  • Phone: 270-726-9049
  • Fax:
Mailing address:
  • Phone: 502-438-7771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MICK VUJANOVIC
Title or Position: CEO
Credential:
Phone: 502-667-8150