1811430978 NPI number — PENTECOSTAL CHILDREN'S HOME

Table of content: (NPI 1811430978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811430978 NPI number — PENTECOSTAL CHILDREN'S HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENTECOSTAL CHILDREN'S HOME
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:
APPALACHIAN CHILDREN'S HOME
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:
1811430978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARBOURVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40906-0550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-546-3805
Provider Business Mailing Address Fax Number:
606-546-3903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1909 KY 3439
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBOURVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40906-7201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-546-3805
Provider Business Practice Location Address Fax Number:
606-546-3903
Provider Enumeration Date:
11/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
TREATMENT DIRECTOR
Authorized Official Telephone Number:
606-546-3805

Provider Taxonomy Codes

  • Taxonomy code: 253J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 322D00000X , with the licence number: 800232 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3245S0500X , with the licence number: 810530 , 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)





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