1134124167 NPI number — COMMONWEALTH OF KENTUCKY

Table of content: (NPI 1134124167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134124167 NPI number — COMMONWEALTH OF KENTUCKY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH OF KENTUCKY
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:
6
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:
1134124167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2200
Provider Second Line Business Mailing Address:
2400 RUSSELLVILLE ROAD, US 68 EAST
Provider Business Mailing Address City Name:
HOPKINSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-886-4431
Provider Business Mailing Address Fax Number:
270-886-4487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 RUSSELLVILLE RD
Provider Second Line Business Practice Location Address:
US 68 EAST
Provider Business Practice Location Address City Name:
HOPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-886-4431
Provider Business Practice Location Address Fax Number:
270-886-4487
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
502-782-6117

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 313M00000X , with the licence number: 100490 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 315P00000X , 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: 12400024 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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