MEDICARE: COMMUNITY CARE OF KENTUCKY, 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	1223G0001X	General Practice Dentistry

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	:	1811375785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE OF KENTUCKY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2369
Second Line	:
City	:	ANNISTON
State	:	AL
Zip	:	36202-2369
Country	:	US
Telephone Number	:	256-241-3965
Fax Number	:	256-241-1698

Provider Business Practice Location Address
First Line	:	2500 W BROADWAY STE 100
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40211-1184
Country	:	US
Telephone Number	:	502-776-1754
Fax Number	:	502-778-2301

Authorized Official
Title or Position	:	MANAGER, LICENSING & CREDENTIALING
Name	:	JENELL STUMP
Credential	:
Telephone Number	:	629-999-5006

Provider Enumeration Date	:	05/12/2015
Last Update Date	:	05/07/2018

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