Provider Demographics
NPI:1811132350
Name:TRILOGY HEALTHCARE OF JEFFERSON, LLC
Entity type:Organization
Organization Name:TRILOGY HEALTHCARE OF JEFFERSON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP - FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:P
Authorized Official - Last Name:PLEVYAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:502-213-1710
Mailing Address - Street 1:3625 FERN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-1916
Mailing Address - Country:US
Mailing Address - Phone:502-964-3381
Mailing Address - Fax:502-964-7414
Practice Address - Street 1:3625 FERN VALLEY RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1916
Practice Address - Country:US
Practice Address - Phone:502-964-3381
Practice Address - Fax:502-964-7414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRILOGY FSC INVESTORS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100196314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12504221Medicaid
KY185132Medicare Oscar/Certification