Provider Demographics
NPI:1134124167
Name:COMMONWEALTH OF KENTUCKY
Entity Type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:WESTERN STATE NURSING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAYCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-782-6243
Mailing Address - Street 1:PO BOX 2200
Mailing Address - Street 2:2400 RUSSELLVILLE ROAD, US 68 EAST
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241
Mailing Address - Country:US
Mailing Address - Phone:502-886-4431
Mailing Address - Fax:270-886-4487
Practice Address - Street 1:2400 RUSSELLVILLE RD
Practice Address - Street 2:US 68 EAST
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42241
Practice Address - Country:US
Practice Address - Phone:502-886-4431
Practice Address - Fax:270-886-4487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-16
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2084P0800X, 313M00000X, 315P00000X
KY100490313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12400024Medicaid
KY184002Medicare Oscar/Certification
KY185228Medicare UPIN
KY3993Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER