1407845639 NPI number — NEW JACKSON MANOR, LLC

Table of content: (NPI 1407845639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407845639 NPI number — NEW JACKSON MANOR, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW JACKSON MANOR, 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:
ANNVILLE ADULT DAY HEALTHCARE 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:
1407845639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9510 ORMSBY STATION ROAD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-753-6004
Provider Business Mailing Address Fax Number:
502-753-6104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
68 HWY 3444
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-364-5197
Provider Business Practice Location Address Fax Number:
606-364-2293
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BARBER
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
502-753-6004

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0600X , with the licence number: 750066 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: 100602 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7100174140 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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