Provider Demographics
NPI: | 1831316595 |
---|---|
Name: | THE PRINCECARE GROUP |
Entity Type: | Organization |
Organization Name: | THE PRINCECARE GROUP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | JIM |
Authorized Official - Middle Name: | DEWAYNE |
Authorized Official - Last Name: | HISLE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 502-428-9037 |
Mailing Address - Street 1: | 1520 BAXTER AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | LOUISVILLE |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40205-1009 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 502-896-8147 |
Mailing Address - Fax: | 502-896-8149 |
Practice Address - Street 1: | 1520 BAXTER AVE |
Practice Address - Street 2: | |
Practice Address - City: | LOUISVILLE |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40205 |
Practice Address - Country: | US |
Practice Address - Phone: | 502-896-8147 |
Practice Address - Fax: | 502-896-8149 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-04-20 |
Last Update Date: | 2018-07-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
225100000X, 225X00000X, 235Z00000X, 251C00000X, 261Q00000X, 261QD1600X | ||
KY | 7100233390 | 261QA0600X |
KY | 7100199960 | 261QP2000X |
KY | 261QR0400X | |
KY | 7100010990 | 320900000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | ||
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | Group - Multi-Specialty | |
No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | Group - Multi-Specialty | |
No | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | Group - Multi-Specialty |
No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | Group - Multi-Specialty |
No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | Group - Multi-Specialty |
No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | Group - Multi-Specialty |