=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568790665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FERN TERRACE OF OWENSBORO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2009
-----------------------------------------------------
Last Update Date | 12/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 WOODFORD AVE
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42301-0563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-684-7171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 WOODFORD AVE
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42301-0563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-683-5571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. HARRY D SIMPSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-683-5571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 100096
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------