Healthcare Provider Details

I. General information

NPI: 1770762833
Provider Name (Legal Business Name): COMMONWEALTH OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5659 MAIN ST
THELMA KY
41260-8609
US

IV. Provider business mailing address

5659 MAIN ST
THELMA KY
41260-8609
US

V. Phone/Fax

Practice location:
  • Phone: 606-788-6600
  • Fax: 606-788-7076
Mailing address:
  • Phone: 606-788-6600
  • Fax: 606-788-7076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. GAYLENE MORROW
Title or Position: BILLING CLERK
Credential:
Phone: 606-788-6600