MEDICARE: SPECTRE & QUEEN

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	385H00000X	Respite Care	500280	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	500280	OTHER	KY	COMMONWEALTH OF KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES

General Provider Information

NPI Number	:	1982123212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRE & QUEEN

Provider Business Mailing Address
First Line	:	326 S COURT ST
Second Line	:
City	:	GRAYSON
State	:	KY
Zip	:	41143-1269
Country	:	US
Telephone Number	:	606-393-0669
Fax Number	:	606-393-0675

Provider Business Practice Location Address
First Line	:	326 S COURT ST
Second Line	:
City	:	GRAYSON
State	:	KY
Zip	:	41143-1269
Country	:	US
Telephone Number	:	606-393-0669
Fax Number	:	606-393-0675

Authorized Official
Title or Position	:	CO-OWNER
Name	:	SHADOW LEE SKAGGS
Credential	:
Telephone Number	:	606-393-0669

Provider Enumeration Date	:	09/19/2017
Last Update Date	:	07/21/2022

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Directions to “SPECTRE & QUEEN ” Practice Location

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