Provider Demographics
NPI:1275745176
Name:FIVCO ADD CDO AS FISCAL AGENT
Entity Type:Organization
Organization Name:FIVCO ADD CDO AS FISCAL AGENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-929-1366
Mailing Address - Street 1:1212 BATH AVE.
Mailing Address - Street 2:SUITE 650
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101
Mailing Address - Country:US
Mailing Address - Phone:606-929-1366
Mailing Address - Fax:606-327-0023
Practice Address - Street 1:1212 BATH AVE.
Practice Address - Street 2:SUITE 650
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-929-1366
Practice Address - Fax:606-327-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33001447Medicaid
KY43996107Medicaid
KY17000811Medicaid