Provider Demographics
NPI:1629001052
Name:LIFELINE HEALTH CARE OF KENTUCKY, INC.
Entity Type:Organization
Organization Name:LIFELINE HEALTH CARE OF KENTUCKY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-4100
Mailing Address - Street 1:600 CLIFTY ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1733
Mailing Address - Country:US
Mailing Address - Phone:606-679-4100
Mailing Address - Fax:606-678-7306
Practice Address - Street 1:1600 SCOTTSVILLE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3217
Practice Address - Country:US
Practice Address - Phone:270-781-0702
Practice Address - Fax:270-781-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251E00000XAgenciesHome Health
Not Answered251J00000XAgenciesNursing Care
Not Answered261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Not Answered261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY42031146Medicaid
KY34071142Medicaid
KY45342557Medicaid
KY41114034Medicaid
KY41114034Medicaid