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General NPI Number Information
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NPI Number | 1194862599
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH OF KENTUCKY
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 08/07/2024
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Provider Practice Location Address
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Address Line | 23524 DAWSON SPRINGS RD
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City | DAWSON SPRINGS
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State | KY
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Zip | 42408-9205
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Country | US
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Telephone | 270-797-3771
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Fax | 270-797-3592
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Provider Business Mailing Address
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Address Line | 9901 LINN STATION RD
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City | LOUISVILLE
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State | KY
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Zip | 40223-3808
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Country | US
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Telephone | 800-866-0860
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Fax |
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Authorized Official
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Title or Position | ASSISTANT DIRECTOR
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Name | JENNIFER MOORE
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Credential |
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Telephone | 502-782-6117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 100458
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License Number State | KY
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