=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063458974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HANGING ROCK LTC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 07/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9600 LAMBORNE BLVD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40272-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-935-7284
-----------------------------------------------------
Fax | 502-933-5977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9600 LAMBORNE BLVD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40272-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-935-7284
-----------------------------------------------------
Fax | 502-933-5977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | GALE BOICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-523-9094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 100518
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------