Provider Demographics
NPI:1811375785
Name:COMMUNITY CARE OF KENTUCKY, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF KENTUCKY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LICENSING & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-999-5006
Mailing Address - Street 1:PO BOX 2369
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36202-2369
Mailing Address - Country:US
Mailing Address - Phone:256-241-3965
Mailing Address - Fax:256-241-1698
Practice Address - Street 1:2500 W BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1184
Practice Address - Country:US
Practice Address - Phone:502-776-1754
Practice Address - Fax:502-778-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100298140Medicaid