Provider Demographics
NPI:1114926854
Name:GRAYSON COUNTY HOSPITAL FOUNDATION INC.
Entity Type:Organization
Organization Name:GRAYSON COUNTY HOSPITAL FOUNDATION INC.
Other - Org Name:TWIN LAKES HOME HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HOME HEALTH
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:FULKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:270-259-9525
Mailing Address - Street 1:910 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1418
Mailing Address - Country:US
Mailing Address - Phone:270-259-9525
Mailing Address - Fax:270-259-1670
Practice Address - Street 1:910 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1418
Practice Address - Country:US
Practice Address - Phone:270-259-9525
Practice Address - Fax:270-259-1670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY150102251E00000X, 251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000054567OtherANTHEM
KY42001438Medicaid
KY34001446Medicaid
KY1050335Medicaid
KY2432817000OtherPASSPORT ADVANTAGE
KY000000054567OtherANTHEM