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General NPI Number Information
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NPI Number | 1639714843
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Entity Type | Organization
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Legal Business Name | KENTUCKY CUSTOM CARE PROFESSIONALS
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Dates
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Enumeration Date | 11/12/2019
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Last Update Date | 11/12/2019
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Provider Practice Location Address
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Address Line | 3200 PATTON RD
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City | BOSTON
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State | KY
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Zip | 40107-4010
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Country | US
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Telephone | 502-331-1085
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Fax |
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Provider Business Mailing Address
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Address Line | 3200 PATTON RD
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City | BOSTON
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State | KY
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Zip | 40107-8700
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Country | US
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Telephone | 502-331-1085
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KIMBERLY FENWICK
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Credential | CPA
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Telephone | 502-331-1085
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number |
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License Number State |
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