Healthcare Provider Details

I. General information

NPI: 1386863561
Provider Name (Legal Business Name): COMMONWEALTH OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 VETERANS DR
WILMORE KY
40390-9775
US

IV. Provider business mailing address

100 VETERANS DR
WILMORE KY
40390-9775
US

V. Phone/Fax

Practice location:
  • Phone: 859-858-2814
  • Fax: 859-858-4039
Mailing address:
  • Phone: 859-858-2814
  • Fax: 859-858-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number100651
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100651
License Number StateKY

VIII. Authorized Official

Name: MR. BEN SWEGER
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 502-564-9281