Provider Demographics
NPI:1780661868
Name:WESLEY MANOR RETIREMENT COMMUNITY INC.
Entity Type:Organization
Organization Name:WESLEY MANOR RETIREMENT COMMUNITY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMIN CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-969-3277
Mailing Address - Street 1:5012 E MANSLICK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-5165
Mailing Address - Country:US
Mailing Address - Phone:502-969-3277
Mailing Address - Fax:502-969-3270
Practice Address - Street 1:5012 E MANSLICK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-5165
Practice Address - Country:US
Practice Address - Phone:502-969-3277
Practice Address - Fax:502-969-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100230313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12500609Medicaid
KY12500609Medicaid