Provider Demographics
NPI:1083697452
Name:MT. LEBANON PERSONAL CARE HOME INC.
Entity Type:Organization
Organization Name:MT. LEBANON PERSONAL CARE HOME INC.
Other - Org Name:DBA- JAMES S TAYLOR MEMORIAL HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:CMA, CFO
Authorized Official - Phone:502-589-0727
Mailing Address - Street 1:1015 MAGAZINE STREET
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203
Mailing Address - Country:US
Mailing Address - Phone:502-589-0727
Mailing Address - Fax:502-589-3086
Practice Address - Street 1:1015 MAGAZINE STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203
Practice Address - Country:US
Practice Address - Phone:502-589-0727
Practice Address - Fax:502-589-3086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100536313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12502126Medicaid
185448Medicare UPIN