Provider Demographics
NPI:1164785846
Name:MASONIC HOMES OF KENTUCKY PEDIATRIC DAYCARE INC
Entity Type:Organization
Organization Name:MASONIC HOMES OF KENTUCKY PEDIATRIC DAYCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BODEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-753-8224
Mailing Address - Street 1:330 MASONIC HOME DR
Mailing Address - Street 2:
Mailing Address - City:MASONIC HOME
Mailing Address - State:KY
Mailing Address - Zip Code:40041-9000
Mailing Address - Country:US
Mailing Address - Phone:502-753-8224
Mailing Address - Fax:502-753-8223
Practice Address - Street 1:330 MASONIC HOME DR
Practice Address - Street 2:
Practice Address - City:MASONIC HOME
Practice Address - State:KY
Practice Address - Zip Code:40041-9000
Practice Address - Country:US
Practice Address - Phone:502-753-8224
Practice Address - Fax:502-753-8223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASONIC HOMES OF KENTUCKY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty