Provider Demographics
NPI:1326020348
Name:EVAN GRAY, LLC
Entity Type:Organization
Organization Name:EVAN GRAY, LLC
Other - Org Name:FLORENCE PARK CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-605-2700
Mailing Address - Street 1:12500 REED HARTMAN HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-1892
Mailing Address - Country:US
Mailing Address - Phone:513-605-2700
Mailing Address - Fax:513-605-2731
Practice Address - Street 1:6975 BURLINGTON PIKE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1618
Practice Address - Country:US
Practice Address - Phone:513-605-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100547314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12504312Medicaid
KY185174Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER