Healthcare Provider Details

I. General information

NPI: 1437148046
Provider Name (Legal Business Name): DJ LETCHER MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 PIEDMONT DR
WHITESBURG KY
41858-7668
US

IV. Provider business mailing address

300 PROVIDER CT SUITE 100
RICHMOND KY
40475-8488
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-1434
  • Fax: 606-633-3450
Mailing address:
  • Phone: 859-623-0898
  • Fax: 859-623-0843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100604
License Number StateKY

VIII. Authorized Official

Name: MRS. KIMBERLY MORROW
Title or Position: VP OF ADMINISTRATIVE SUPPORT
Credential:
Phone: 859-623-0898