Provider Demographics
NPI:1346890878
Name:RUSSELLVILLE KY OPCO LLC
Entity type:Organization
Organization Name:RUSSELLVILLE KY OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICK
Authorized Official - Middle Name:
Authorized Official - Last Name:VUJANOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-667-8150
Mailing Address - Street 1:2100 CHEROKEE RIDGE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1600
Mailing Address - Country:US
Mailing Address - Phone:502-438-7771
Mailing Address - Fax:
Practice Address - Street 1:107 BOYLES DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-8838
Practice Address - Country:US
Practice Address - Phone:270-726-9049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care