=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861244097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLE HOMESCHOOL SUPPORT GROUP & RESOURCE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2024
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 N RICE AVE
-----------------------------------------------------
City | LOUISA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41230-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-638-0032
-----------------------------------------------------
Fax | 606-638-0032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 N RICE AVE
-----------------------------------------------------
City | LOUISA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41230-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-638-0032
-----------------------------------------------------
Fax | 606-638-0032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | GENA LYNN RENO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-702-3983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------