=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205596079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINCOLN TRAIL HOMECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2021
-----------------------------------------------------
Last Update Date | 12/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 MANOR AVE STE 201
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-348-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 MANOR AVE STE 201
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-348-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL MCCANCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-348-0377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------