Provider Demographics
NPI:1639310881
Name:GC HOME HOLDINGS, LLC
Entity Type:Organization
Organization Name:GC HOME HOLDINGS, LLC
Other - Org Name:PROVIDENCE PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:859-261-5231
Mailing Address - Street 1:4322 ALEXANDRIA PIKE
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-1918
Mailing Address - Country:US
Mailing Address - Phone:859-261-5231
Mailing Address - Fax:859-261-1008
Practice Address - Street 1:401 E 20TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41014-1583
Practice Address - Country:US
Practice Address - Phone:859-283-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100266314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100081080Medicaid
KY185038OtherMEDICARE PROVIDER NUMBER