Provider Demographics
NPI:1154341923
Name:MASONIC HOMES OF KENTUCKY INC
Entity type:Organization
Organization Name:MASONIC HOMES OF KENTUCKY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:LACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-753-8802
Mailing Address - Street 1:240 MASONIC HOME DR
Mailing Address - Street 2:
Mailing Address - City:MASONIC HOME
Mailing Address - State:KY
Mailing Address - Zip Code:40041-9000
Mailing Address - Country:US
Mailing Address - Phone:502-897-4907
Mailing Address - Fax:502-259-5290
Practice Address - Street 1:240 MASONIC HOME DR
Practice Address - Street 2:
Practice Address - City:MASONIC HOME
Practice Address - State:KY
Practice Address - Zip Code:40041-9000
Practice Address - Country:US
Practice Address - Phone:502-897-4907
Practice Address - Fax:502-259-5290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100225314000000X
KY760006320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000054518OtherANTHEM
KY12502662Medicaid
KY000000054518OtherANTHEM
KY185388Medicare Oscar/Certification