Provider Demographics
NPI:1497734990
Name:HQM OF BRACKEN COUNTY, INC
Entity Type:Organization
Organization Name:HQM OF BRACKEN COUNTY, INC
Other - Org Name:BRACKEN COUNTY NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-627-0664
Mailing Address - Street 1:5269 ASBURY RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KY
Mailing Address - Zip Code:41002-9215
Mailing Address - Country:US
Mailing Address - Phone:606-756-2156
Mailing Address - Fax:
Practice Address - Street 1:5269 ASBURY RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KY
Practice Address - Zip Code:41002-9215
Practice Address - Country:US
Practice Address - Phone:606-756-2156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100039314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12504023Medicaid
KY18-5344Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER