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General NPI Number Information
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NPI Number | 1679571830
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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 | 07/12/2005
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Last Update Date | 02/19/2018
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Provider Practice Location Address
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Address Line | 2441 SOUTH HIGHWAY 27
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City | SOMERSET
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State | KY
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Zip | 42501
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Country | US
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Telephone | 606-677-4068
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Fax | 606-677-4079
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Provider Business Mailing Address
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Address Line | 2441 SOUTH HIGHWAY 27
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City | SOMERSET
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State | KY
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Zip | 42501
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Country | US
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Telephone | 606-677-4068
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Fax | 606-677-4079
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Authorized Official
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Title or Position | DIRECTOR
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Name | STEPHANIE CRAYCRAFT
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Credential |
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Telephone | 502-782-6243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 100426
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | PO5076
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | PO5076
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License Number State | KY
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