Provider Demographics
NPI:1194707711
Name:INTREPID OF THE TRI-STATE, INC.
Entity type:Organization
Organization Name:INTREPID OF THE TRI-STATE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUNYSZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:14841 DALLAS PKWY STE 625
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7641
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:201 KLUTEY PARK PLAZA
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-3345
Practice Address - Country:US
Practice Address - Phone:270-827-4842
Practice Address - Fax:270-827-8244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY150114251E00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY42000133Medicaid
KY34000224Medicaid
KY42000133Medicaid