Provider Demographics
NPI:1285186924
Name:PIONEER TRACE GROUP, LLC
Entity Type:Organization
Organization Name:PIONEER TRACE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:270-839-1589
Mailing Address - Street 1:115 PIONEER TRCE
Mailing Address - Street 2:
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041-9665
Mailing Address - Country:US
Mailing Address - Phone:606-845-2131
Mailing Address - Fax:606-845-3507
Practice Address - Street 1:115 PIONEER TRCE
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041-9665
Practice Address - Country:US
Practice Address - Phone:606-845-2131
Practice Address - Fax:606-845-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100484314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY100484OtherFACILITY LICENSE