Provider Demographics
NPI:1508032889
Name:WESLEY MANOR NURSING HOME
Entity Type:Organization
Organization Name:WESLEY MANOR NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. ADMIN. / CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-969-3277
Mailing Address - Street 1:5012 E MANSLICK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-5165
Mailing Address - Country:US
Mailing Address - Phone:502-969-3277
Mailing Address - Fax:502-969-3259
Practice Address - Street 1:5012 E MANSLICK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-5165
Practice Address - Country:US
Practice Address - Phone:502-969-3277
Practice Address - Fax:502-969-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100230235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000054578OtherANTHEM BCBS