Provider Demographics
NPI:1467434043
Name:INTREPID OF SOUTHERN KENTUCKY, INC.
Entity Type:Organization
Organization Name:INTREPID OF SOUTHERN KENTUCKY, INC.
Other - Org Name:INTREPID USA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:14841 DALLAS PKWY STE 625
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7641
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3994
Practice Address - Street 1:230 TOWER CIR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3480
Practice Address - Country:US
Practice Address - Phone:606-679-7439
Practice Address - Fax:606-678-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY150031225100000X, 251E00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45002367Medicaid
KY34000182Medicaid
KY42000117Medicaid
KY187022Medicare Oscar/Certification