Provider Demographics
NPI:1578549184
Name:LIVINGSTON HOSPITAL AND HEALTHCARE SERVICES, INC.
Entity Type:Organization
Organization Name:LIVINGSTON HOSPITAL AND HEALTHCARE SERVICES, INC.
Other - Org Name:GRAND LAKES CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-988-2299
Mailing Address - Street 1:131 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-8043
Mailing Address - Country:US
Mailing Address - Phone:270-988-2299
Mailing Address - Fax:270-988-3900
Practice Address - Street 1:1860 JH OBRYAN AVE
Practice Address - Street 2:
Practice Address - City:GRAND RIVERS
Practice Address - State:KY
Practice Address - Zip Code:42045-9049
Practice Address - Country:US
Practice Address - Phone:703-628-2462
Practice Address - Fax:270-362-9757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9000135261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3500140300Medicaid
KY000000072411OtherBC/BS
KY3500140300Medicaid
KY183448Medicare Oscar/Certification