Provider Demographics
NPI:1609092113
Name:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY, INC
Entity Type:Organization
Organization Name:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:HATTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-259-9101
Mailing Address - Street 1:PO BOX 18067
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40261-0067
Mailing Address - Country:US
Mailing Address - Phone:502-499-9383
Mailing Address - Fax:
Practice Address - Street 1:2116 BUECHEL BANK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3521
Practice Address - Country:US
Practice Address - Phone:502-499-9383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004650225100000X
KYR1071225X00000X
KYR3513225X00000X
KY2655235Z00000X
KY101046261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
186652Medicare PIN