Provider Demographics
NPI:1093982795
Name:NORTHERN KENTUCKY CONSUMER DIRECTED OPTION PROGRAM
Entity Type:Organization
Organization Name:NORTHERN KENTUCKY CONSUMER DIRECTED OPTION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-283-1885
Mailing Address - Street 1:22 SPIRAL DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 SPIRAL DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1300
Practice Address - Country:US
Practice Address - Phone:859-283-1885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY17000787Medicaid