MEDICARE: NATHANIEL HOUSE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	33000324	KY
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	33000324	KY

General Provider Information

NPI Number	:	1447452925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATHANIEL HOUSE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2078
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40476-2078
Country	:	US
Telephone Number	:	859-626-3502
Fax Number	:	859-626-1620

Provider Business Practice Location Address
First Line	:	137 PINE ST
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-1941
Country	:	US
Telephone Number	:	859-626-3502
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. DAWNE M. DEBOARD
Credential	:
Telephone Number	:	859-626-3502

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	08/25/2016

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