1588804546 NPI number — COMMONWEALTH OF KENTUCKY

Table of content: (NPI 1588804546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588804546 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:
1588804546
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:
400 EASTWOOD DR
Provider Second Line Business Mailing Address:
2441 S. HWY 27
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-677-4068
Provider Business Mailing Address Fax Number:
606-677-4079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 EASTWOOD DR
Provider Second Line Business Practice Location Address:
2441 S. HWY 27
Provider Business Practice Location Address City Name:
SOMERSETQ
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-677-4068
Provider Business Practice Location Address Fax Number:
606-677-4079
Provider Enumeration Date:
03/03/2009

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: 315P00000X , with the licence number:  100426 , 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: 11900008 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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