=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689652513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMONWEALTH OF KENTUCKY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2005
-----------------------------------------------------
Last Update Date | 08/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 MEADOWS DR
-----------------------------------------------------
City | MT WASHINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40047-6013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-361-2301
-----------------------------------------------------
Fax | 502-363-6114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 MEADOWS DR
-----------------------------------------------------
City | MT WASHINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40047-6013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-361-2301
-----------------------------------------------------
Fax | 502-363-6114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT DIRECTOR
-----------------------------------------------------
Name | JENNIFER MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-782-6117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 100695
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------