Healthcare Provider Details

I. General information

NPI: 1194983817
Provider Name (Legal Business Name): SHILOH CITY OF PEACE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 BRIGGS LN
VINE GROVE KY
40175-9418
US

IV. Provider business mailing address

280 BRIGGS LN
VINE GROVE KY
40175-9418
US

V. Phone/Fax

Practice location:
  • Phone: 270-300-1841
  • Fax:
Mailing address:
  • Phone: 270-300-1841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAQUITA GASKINS
Title or Position: CEO
Credential:
Phone: 270-300-1841