Provider Demographics
NPI:1164447124
Name:EASTER SEALS WEST KENTUCKY
Entity Type:Organization
Organization Name:EASTER SEALS WEST KENTUCKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADULT SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-443-1200
Mailing Address - Street 1:801 N 29TH ST.
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001
Mailing Address - Country:US
Mailing Address - Phone:270-443-1200
Mailing Address - Fax:270-444-0655
Practice Address - Street 1:2229 MILDRED ST.
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001
Practice Address - Country:US
Practice Address - Phone:270-443-1200
Practice Address - Fax:270-444-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY750088261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY43005735Medicaid