Provider Demographics
NPI:1659673655
Name:MODERN CARE LLC
Entity Type:Organization
Organization Name:MODERN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SANDUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:502-523-8044
Mailing Address - Street 1:104 NANCY COX DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-6834
Mailing Address - Country:US
Mailing Address - Phone:270-465-8508
Mailing Address - Fax:270-465-8504
Practice Address - Street 1:104 NANCY COX DR
Practice Address - Street 2:SUITE D
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-6834
Practice Address - Country:US
Practice Address - Phone:270-465-8508
Practice Address - Fax:270-465-8504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
311Z00000X
KY311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100144580Medicaid