1801909304 NPI number — KLONDIKE MANOR, LLC

Table of content: (NPI 1801909304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801909304 NPI number — KLONDIKE MANOR, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KLONDIKE 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:
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:
1801909304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SUN AVE NE
Provider Second Line Business Mailing Address:
COMPLIANCE DEPARTMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-4373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-468-5604
Provider Business Mailing Address Fax Number:
505-468-4681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3802 KLONDIKE LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-1796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-452-1579
Provider Business Practice Location Address Fax Number:
502-451-9310
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATHIES
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT DIRECTOR
Authorized Official Telephone Number:
505-821-3355

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  100424 , 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: 12504833 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com