1669495131 NPI number — MASONIC HOMES OF KENTUCKY INC

Table of content: (NPI 1669495131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669495131 NPI number — MASONIC HOMES OF KENTUCKY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASONIC HOMES OF KENTUCKY INC
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:
Provider Other Organization Name Type Code:
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:
1669495131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 FRANKFORT RD
Provider Second Line Business Mailing Address:
P.O. BOX 909
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40065-9447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-633-3486
Provider Business Mailing Address Fax Number:
502-633-0661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 FRANKFORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-9447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-633-3486
Provider Business Practice Location Address Fax Number:
502-633-0661
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FINNERAN
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
502-633-3486

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  100386 , 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: 12502571 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000054519 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2438960000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5394544 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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