Provider Demographics
NPI:1275182255
Name:THE KIDZ CLUB-PDN, LLC
Entity Type:Organization
Organization Name:THE KIDZ CLUB-PDN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-724-9831
Mailing Address - Street 1:1101 HERR LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4301
Mailing Address - Country:US
Mailing Address - Phone:502-210-5538
Mailing Address - Fax:502-327-5098
Practice Address - Street 1:1537 HIGHWAY 185
Practice Address - Street 2:SUITE 3
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:502-210-5538
Practice Address - Fax:502-327-5098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY720506Medicaid