MEDICARE: COMMONWEALTH OF KENTUCKY

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	100695	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689652513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF KENTUCKY

Provider Business Mailing Address
First Line	:	210 MEADOWS DR
Second Line	:
City	:	MT WASHINGTON
State	:	KY
Zip	:	40047-6013
Country	:	US
Telephone Number	:	502-361-2301
Fax Number	:	502-363-6114

Provider Business Practice Location Address
First Line	:	210 MEADOWS DR
Second Line	:
City	:	MT WASHINGTON
State	:	KY
Zip	:	40047-6013
Country	:	US
Telephone Number	:	502-361-2301
Fax Number	:	502-363-6114

Authorized Official
Title or Position	:	ASSISTANT DIRECTOR
Name	:	JENNIFER MOORE
Credential	:
Telephone Number	:	502-782-6117

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	08/07/2024

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