Provider Demographics
NPI:1376747519
Name:PROVIDENCE IND. SCHOOLS
Entity Type:Organization
Organization Name:PROVIDENCE IND. SCHOOLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:KY DEPT. OF EDUCATION
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEISEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:2706-677-0017
Mailing Address - Street 1:302 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-1140
Mailing Address - Country:US
Mailing Address - Phone:270-667-7007
Mailing Address - Fax:270-667-7606
Practice Address - Street 1:302 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1140
Practice Address - Country:US
Practice Address - Phone:270-667-7007
Practice Address - Fax:270-667-7606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY21117015Medicaid