Provider Demographics
NPI:1275522559
Name:MENIFEE COUNTY NURSING HOME CORPORATION
Entity Type:Organization
Organization Name:MENIFEE COUNTY NURSING HOME CORPORATION
Other - Org Name:EDGEWOOD ESTATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:606-768-9001
Mailing Address - Street 1:195 BERRYMAN RD
Mailing Address - Street 2:
Mailing Address - City:FRENCHBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40322-8496
Mailing Address - Country:US
Mailing Address - Phone:606-768-9001
Mailing Address - Fax:606-768-9005
Practice Address - Street 1:195 BERRYMAN RD
Practice Address - Street 2:
Practice Address - City:FRENCHBURG
Practice Address - State:KY
Practice Address - Zip Code:40322-8496
Practice Address - Country:US
Practice Address - Phone:606-768-9001
Practice Address - Fax:606-768-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100700314000000X
KY750060385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54911OtherANTHEM
KY12503108Medicaid
KY43002831Medicaid
KY1127890001Medicare NSC
KY185423Medicare Oscar/Certification