Provider Demographics
NPI:1528636057
Name:PHILLIPS, JOHN CALEB (UNIT MANAGER LPN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CALEB
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:UNIT MANAGER LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DAVCO DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 DAVCO DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8477
Practice Address - Country:US
Practice Address - Phone:859-236-5383
Practice Address - Fax:859-270-7696
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2052375164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY364SL0600XOtherASSISTED LIVING