1063458974 NPI number — HANGING ROCK LTC, LLC

Table of content: (NPI 1063458974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063458974 NPI number — HANGING ROCK LTC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HANGING ROCK LTC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ESSEX NURSING AND REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063458974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9600 LAMBORNE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40272-2505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-935-7284
Provider Business Mailing Address Fax Number:
502-933-5977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9600 LAMBORNE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40272-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-935-7284
Provider Business Practice Location Address Fax Number:
502-933-5977
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOICE
Authorized Official First Name:
GALE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
252-523-9094

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  100518 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000000219014 . This is a "BCBS OF KY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100169010 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12501680 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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