Provider Demographics
NPI:1003818303
Name:LARUE COUNTY GERIATRIC CENTER, INC.
Entity Type:Organization
Organization Name:LARUE COUNTY GERIATRIC CENTER, INC.
Other - Org Name:SUNRISE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOYALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-358-3103
Mailing Address - Street 1:80 PHILLIPS LN
Mailing Address - Street 2:
Mailing Address - City:HODGENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42748-1645
Mailing Address - Country:US
Mailing Address - Phone:270-358-3103
Mailing Address - Fax:270-358-8412
Practice Address - Street 1:80 PHILLIPS LN
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1645
Practice Address - Country:US
Practice Address - Phone:270-358-3103
Practice Address - Fax:270-358-8412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY750086261QA0600X
KY100277314000000X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY43010628Medicaid
KY12502233Medicaid
KY100277Medicaid
KY12502233Medicaid
KY185057Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER