Provider Demographics
NPI:1366157521
Name:HAYATT SUPPORTED COMMUNITY LIVING LLC
Entity type:Organization
Organization Name:HAYATT SUPPORTED COMMUNITY LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BASMA
Authorized Official - Middle Name:M
Authorized Official - Last Name:YAQAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-893-9432
Mailing Address - Street 1:3608 BROOKS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:KY
Mailing Address - Zip Code:42036-9171
Mailing Address - Country:US
Mailing Address - Phone:270-873-9432
Mailing Address - Fax:
Practice Address - Street 1:3608 BROOKS CHAPEL RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:KY
Practice Address - Zip Code:42036-9171
Practice Address - Country:US
Practice Address - Phone:270-873-9432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities