Provider Demographics
NPI:1083785125
Name:COMMONWEALTH OF KENTUCKY
Entity Type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:BINGHAM GARDENS ICF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-564-4527
Mailing Address - Street 1:4401-4505 LOUISE UNDERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216
Mailing Address - Country:US
Mailing Address - Phone:502-363-8421
Mailing Address - Fax:
Practice Address - Street 1:4401-4505 LOUISE UNDERWOOD WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216
Practice Address - Country:US
Practice Address - Phone:502-363-6421
Practice Address - Fax:502-363-2215
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-12
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY11906260Medicaid