Provider Demographics
NPI:1548402720
Name:CHRISTIAN CARE CENTER OF KUTTAWA, LLC
Entity Type:Organization
Organization Name:CHRISTIAN CARE CENTER OF KUTTAWA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RISK CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAWOOD-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-975-5455
Mailing Address - Street 1:2020 NORTHPARK
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3127
Mailing Address - Country:US
Mailing Address - Phone:423-975-5455
Mailing Address - Fax:423-975-5405
Practice Address - Street 1:1253 LAKE BARKLEY DRIVE
Practice Address - Street 2:
Practice Address - City:KUTTAWA
Practice Address - State:KY
Practice Address - Zip Code:42055-6124
Practice Address - Country:US
Practice Address - Phone:270-388-2291
Practice Address - Fax:270-388-0948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100300313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100070570Medicaid
185318Medicare Oscar/Certification
6441880001Medicare NSC