Provider Demographics
NPI:1114192168
Name:EASTER SEALS WEST KENTUCKY
Entity Type:Organization
Organization Name:EASTER SEALS WEST KENTUCKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. ADULT SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-443-1200
Mailing Address - Street 1:2229 MILDRED ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-3067
Mailing Address - Country:US
Mailing Address - Phone:270-443-1200
Mailing Address - Fax:270-444-0655
Practice Address - Street 1:84 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1110
Practice Address - Country:US
Practice Address - Phone:270-527-1332
Practice Address - Fax:270-527-1566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY750148261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100022550Medicaid