Provider Demographics
NPI:1639241433
Name:HICKS ENTERPRISES OF MONTICELLO, LLC
Entity Type:Organization
Organization Name:HICKS ENTERPRISES OF MONTICELLO, LLC
Other - Org Name:HICKS GOLDEN YEARS NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-348-6034
Mailing Address - Street 1:1801 W. HWY. 90 BY-PASS
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633
Mailing Address - Country:US
Mailing Address - Phone:606-348-6034
Mailing Address - Fax:606-348-6521
Practice Address - Street 1:1801 W. HWY. 90 BY-PASS
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633
Practice Address - Country:US
Practice Address - Phone:606-348-6034
Practice Address - Fax:606-348-6521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100485313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12504775Medicaid
KY185298Medicare Oscar/Certification
KY12504775Medicaid