Provider Demographics
NPI:1104813880
Name:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY, INC
Entity type:Organization
Organization Name:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HATTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-259-9101
Mailing Address - Street 1:PO BOX 18067
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40261-0067
Mailing Address - Country:US
Mailing Address - Phone:502-259-9101
Mailing Address - Fax:502-259-9109
Practice Address - Street 1:60 PHILLIPS BRANCH RD
Practice Address - Street 2:
Practice Address - City:PHELPS
Practice Address - State:KY
Practice Address - Zip Code:41553-9061
Practice Address - Country:US
Practice Address - Phone:502-259-9101
Practice Address - Fax:502-259-9109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100516314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12504080Medicaid
KY185222Medicare ID - Type Unspecified
KY1292900001Medicare NSC