Provider Demographics
NPI:1366447609
Name:CENTRAL STATE HOSPITAL
Entity Type:Organization
Organization Name:CENTRAL STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-253-7135
Mailing Address - Street 1:10510 LAGRANGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-1277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:502-253-7044
Practice Address - Street 1:10510 LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-1277
Practice Address - Country:US
Practice Address - Phone:502-253-7135
Practice Address - Fax:502-253-7044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-14
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100198283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY02021293Medicaid
KY02021293Medicaid