Provider Demographics
NPI:1477861888
Name:HOME OF THE INNOCENTS, INC.
Entity Type:Organization
Organization Name:HOME OF THE INNOCENTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-1245
Mailing Address - Street 1:1050 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-1874
Mailing Address - Country:US
Mailing Address - Phone:502-596-1090
Mailing Address - Fax:502-596-1410
Practice Address - Street 1:1050 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1874
Practice Address - Country:US
Practice Address - Phone:502-596-1090
Practice Address - Fax:502-596-1410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY740143261QD0000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY29101185Medicaid
KY7100126000Medicaid
KY12500989Medicaid
KY29201183Medicaid
KY29101185Medicaid