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General NPI Number Information
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NPI Number | 1164785846
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Entity Type | Organization
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Legal Business Name | MASONIC HOMES OF KENTUCKY PEDIATRIC DAYCARE INC
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Dates
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Enumeration Date | 06/19/2012
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Last Update Date | 06/19/2012
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Provider Practice Location Address
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Address Line | 330 MASONIC HOME DR
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City | MASONIC HOME
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State | KY
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Zip | 40041-9000
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Country | US
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Telephone | 502-753-8224
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Fax | 502-753-8223
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Provider Business Mailing Address
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Address Line | 330 MASONIC HOME DR
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City | MASONIC HOME
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State | KY
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Zip | 40041-9000
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Country | US
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Telephone | 502-753-8224
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Fax | 502-753-8223
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | KIM BODEN
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Credential |
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Telephone | 502-753-8224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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