=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881799807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENTUCKY EASTER SEAL SOCIETY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 06/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2050 VERSAILLES RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40504-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-254-5701
-----------------------------------------------------
Fax | 859-233-1615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2050 VERSAILLES RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40504-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-254-5701
-----------------------------------------------------
Fax | 859-233-1615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT/CFO
-----------------------------------------------------
Name | MARTY A. LAUTNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-254-5701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 100100
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | P05154
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 283X00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Hospital
-----------------------------------------------------
License Number | 100100
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------